GW1--03379_Well Construction - GW1_20230515

P rtt Form _
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
eft. a rt. „W f1/ ffari e- zs e
3271-A
im it. Gp ft. . riri�vlC d
NC Well Contractor Certification Number 35,OUTER CASING for multi=easid wells OR•LINER i£a h able
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. / ' rt. in. Jt� +71 J/L
Company Name � r� �i_ I
OWN
16.INNEWCASING OR TUBING. eothermal closed-loop),
2.Well Construction Permit#: .. 3 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): ft. rt. in.
Water Supply Well: 47.'SCREEN- 4:
FROM TO DIAMETER SLOT SIZE THICKNESS 1fATER1AL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT ,
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fit. 20 n. Benote Pour
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge rlGroundwater Remediation 19:SAND/GRAVEL PACK rif applicable). .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage
Experimental Technology Subsidence Control fit. fit.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessir ':'-
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. fit. ec
4.Date Well(s)Completed: Well ID# 0 I b ft. It.
ror✓ ov
5a.Well Location: f Cllb w !b QA
,*3-r teMef LGG 7! /��S !/ 1 fit. /to�7 ft. /� r /1 4�7d S617
Facility/Owner Name Facili y ID#(if applicable) ft. V fit. oC
,23,59 /id!, &170 11/G, a�o3� o /lark
Physical Address,City,and �y IF f ft. ft.
,4 oIn CG, !al//q ir
21.REMARKS,
County Parcel Identification No.(PIN) MAY
A ItA f V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: M 1 5 2023
(if well field,one]at/long is sufficient) 22.Certification:
6.Is(are)the well(s)oPermanent or Temporary Sign urc of ifrcd Wcll o ractor Dat
By signing this, /her y certifyar
that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' r SUBMITTAL INSTRUCTIONS
/�
9.Total well depth below land surface: %D (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
BT' above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: P 1II construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) //r Method of test: Airlift 24c.For Water Suably&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Tabs 13b.Disinfection type: Chlor Tabs Amount: 1 1/2 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 Resources Revised 2-22-2016