GW1--03377_Well Construction - GW1_20230515

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
Well Contractor Name FROM TO I DFSCRIFr10N
3271-A ft. I 4i7 f
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-caacd wells OR LINER if a llcable
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS NATERIAL
Company Name E H w .23 ft- ft 1 9 V2 i"• EDR-21 PVC
7 76.INNER C S G OR TUBING eothertnal closed-loop)
2.Well Construction Permit#: �lli(� � 6 A'01�J FROM To I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permrts(i.e.UIC,C•ouniv.Stare.Variance,etc.) O ft. .( ft. in- 19V
3.Well Use(check well use): ft. 'T ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. It. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
Industrial/Commercial Residential WaMS}tppl}c(s}iared)-r
18.GROUT
Irrigation Er i i , n ?5 �5,.. FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: O ft. 0 ft f�.� �/ Ol/� f'1• GI �7
Monitoring Recovery AY 1 2023 ft.
Injection Well:
A uifcr Rcchar c .® t= U'4 ft. ft.
9 g DGroMd�igr:Rz;ralc lietiottF-"
r�ai 19.SAI�iDIGRAVELPACK d applicable)
Aquifer Storage and Recovery Salinity Barrieh' FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRU LING LOG attach additional sheets if ne
Geothermal(HeatingZCooling Return) n Other(explain under#21 Remarks) FROM To DESC FrION(color.hardness,soiurock in aim,etc.)
4.Date Well(s)Completed:
, /� Well 1D#f.���/�cJ� fa ft. UL/ /-
5a.Well Location: ft. ft .
In a 4mcs LLG Il,'1 . D ft A2) ft ,40
Facil
it
y/OwnerNamcFacility
FacilirylDh(ifapplic Ic) fJf. / 1�0fL ('d
/' h I ffny- T 710fL /y i�.��•rGll4n;OG/lL i%��0 Wit. �irirl�/c r�i
Physical Address,City,and Zip ft. ft.
� 21:REhL4RK5
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field•one lat/long is sufficient) 22.CZED
/
N W 'i4j . 1
6.Is(are)the well(s)OPermanent or Temporary Sign tun of crtificd Well Contra or Date/
B��gning this farm,1 heretic certify that the n.•ell(s) war(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or Qi t� with 15A.NCAC 02C.0100 or 15.4 NCAC 02C.0200 lvell Construction Standards and that a
lfrhis is a repair,fill out known well construction information and explain the nature offhe copy oftnis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
/) SUBMITTAL INSTRUCTIONS
9.rmultiple wells list all depths ijdiffer enr(example Total well depth below land surface: 0- A) 24a. For All Wells: Submit this form within 30 days of completion of well
-3 a•200'arrd 2@100')
For mu/ construction t0 the following:
10.Static water level below top"
casin 40
Ifwarer level is above casing,rove'•P'• g• (ft-) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For Injection Wells: in addition to sending the fomt to the address in 24a
12.Well construction method: Air Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 67 Method of test: /Y 24c.For Water Suvuly&Iniecton Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Rcsobees Rcvised 2-22-2016