GW1--03523_Well Construction - GW1_20230519

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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 DESCRIPTION
3271-A
NC Well Contractor Certification Number R —�y ft. �G�G�t✓
`:15:OUTE OUfER.CASING.formulti=cased'wetls OR:LINER'ifa Hcable
B & K Well Drilling Inc FROM TO DIAMETER THICKVESS MATERIAL
/n ft. //��(it 6112 in. SDR-21 PVC
Company Name (�/ 1/6;INNER CASING OR TUBING. eoth'ermai closed-I
2.Well Construction Permit#: Nu k��✓ I!b& /�/'�/ �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. ft. in.
Water Supply Well: 17'SCREEN.,..;, .:.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Mun' ipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial ©IResidential Water Supply(shared) 7ii GROOT .:
)Irrigation FROM TO MATERIAL E IPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. av ft. t4 ��
Monitoring Recovery ft. ft.
phor
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Rcmcdiation
19 SANiDiGRAVEL:PACIC if cable` s
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD—
Aquifer Test [3StormwaterDrainage ft. ft. MAY 1 Q ,
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRILLING'LOG'attichadditiduslsheets`if" T7T �?a�iPYn1.D'P`'t
FROM TO DESC IPT[ N(color,hard soiVF 'ggrAAld3iu:etc.)
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks) 0 ft. )-5-ft. r -
/
4.Date Well(s)Completed:_� Well ID#lOST 1 7 ft. 3 ft. 1?�Gt/yf
5a.Well Location: / �P ) `, r ft. ft ef-7 f rG 6
_Lcybble creekz 51op1 J� T ' L-)�/ J C ft �f�bft e�D _OL 4 54l7 Oi
Facility/Owner Name /Facility D# if applicable)[f n�d� 0 Uft. / '` ft. L S
S"�tl �L2�yerl3eh� 1Q,� G lyr t4dn-'.V - Q1 0 ft. / bLJ ft. M rr A
Physical Address,City,and Zip fr. ft.
21.REM
/ . ARKS
64J4Z1 GO 337�1003/Iil4 ,-�� d4rl� fhi
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi ation:
N W 7J
6.Is(are)the well(s)oPermanent or Temporary lure of reified We ontmc Dat
signing this fun,, I hereby cer that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or Mixb vr'th ISA NCAC 02C.0100 or 15A NCAC 02C'.0200 Well Construction Standards and that a
!'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 n21 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IJO� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and tea 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 Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) Method of test: i 9�l 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016