GW1--03385_Well Construction - GW1_20230515

,.1
WELL CONSTRUCTION RECORD(GW 1) PnrtF°rin
For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey r4;wnTERzoN>s
Well Contractor Name FROM TO DESCRIPTION
3271-A fL /�>zh-fr
NC Well Contractor Certification Number
.�.tT54`Oii'TER'.CASING fuc'iaaIh-c2se"`RvelLs Oit�I.INEItg if "llci151e �' � .,�B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft C6S ft / �S in..76:=Il!1NE&:Cti91NG,ORTLtB�1G°_'ebthermsl:claveil-Ttio`...
2.Well Construction Permit#: � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
CAgricultural
ll: i7�SGREEN)€;
FROM TO''E• .�s
IAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft. in.
ting/Cooling Supply) Residential Water Supply(single) ft rcial Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Benote wP r'>
Monitoring Recovery
4+' e a •.
Injection Well: ft. ft.
Aquifer Recharge p,3GroundwaterRemediation ft. ft. MAY 9
:19,$e11�ID�GI2A DEL,MCK.Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIA MPLACEMENT METHOD"
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 24 MAMLING,L01 auachadditiouatsheets3f�eces r�v
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO CHIP" ION(color,hardness,soil/rock a rain size,eta)
ft. ` ft (Ji
4.Date Well(s)Completed: Well ID# // ft.
Sa.W ell
/Location-
� kT Gj fL J ft. /�/ J
Vls 3 /J1YlY✓r/.S G✓Facility/O?w/nerName Facility ITD##(if applicable) �� ft• f1/o ft.
/aU/lel' ft. � ft.
Physical Address,City,and Zip ft ft
r>✓Jr// e-_�:
County Parcel Identification No.(PIN) / /^ zi,'/'-// y 5
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C
(if well field,one lai/long is sufficient) 22.Cer tiff ation t
N W
6.Is(are)the wells) Permanent or OTemporary Si cure f Cem ie ell Contra too Dat
8y signing[his jotm,1 herebv cerrfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or MNo with 15A NCAC 02C.0100 or I5A NCAC 01C.0100 Well 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'
/1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SOS' ft.
( ) For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'a)td 1@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
12.Well construction method: /?U TgpV 0,J 1J 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) Method of test: Airlift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs t 1/2 Tabs 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 Resources Revised 2-22-2016