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HomeMy WebLinkAboutGW1--04561_Well Construction - GW1_20230714 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: Joseph Bailey 44: Ai'!.`1L;zoNE ,a' 0:. i4 V4- i'a 1. Well Contractor Name FROM TO DESCRIPT ON 3271-A //Oft. //aft ,, ,, nr 2 ft. ft. NC Well Contractor Certification Number 15:'OITTERG ViiASWG malty Oiedwells)1ORLINEItaii'"licable)B&K Well Drilling Inc FROM TO DIAMETER THICKNESS M TERIAL Company Name Co ft. I M r ft. I / ar in. I ioR a, Lop 33 / 7 h/ _ .6.41NNER;CASINr�G ORT'UBvING(ReothermalVc3Mosedtaop) ZY, a 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.U!C,Coun)),State,Variance,etc.) ft. ft. in. 3.Well Use(check well use): ft. ft. in. Water Supply Well: 17 SCREEN, r ,d FROM TO DIAMETER SLOT SIZE THICKNESS L MATERIAL xJ Agricultural °Municipal/Public ft. ft. in. Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in. Industrial/Commercial OResidential Water Supply(shared) 1&:.GROUT n , : �, .c;«. ..v_ :, ' fc,Irrigation . -�s .� ._ z ... FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT' Non-Water Supply Well: o ft. 20 ft• gt?¢,s /J u V Benote Pour / I 7 !r Monitoring DRecovery ft. ft. Injection Well: Aquifer Recharge ft. ft q g Groundwater Remediation t,,_ , Aquifer Storage and Recove .,19:5A1vD/GRAV,ELLPACICCdapp 1e")"' Y;„ .,.!t,�,�, d,,.�,£�.t ,»a,,y ry °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test 0 Stormwater Drainage ft. ft. J U L 1 is L 023 Experimental Technology °Subsidence Control ft. ft. Geothermal(Closed Loop) OTracer 20 D171LLING':LOo'(attach additional abeets ifrn s FROM TO �) .v�«:.,>:��' Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) DESCRIPTION(c"otolij,7iardness,soilfrock type,gram sire,etc.) 2 4 p 0 ft. /0 ft. [di 4.Date Well(s)Completed: a3 Well ID# J.o x.) iO ft. !Go ft. ,?�yf,,M✓ 9rc,7 5a.Well Location: r10 ft. YO ft. �Q r"" �Lw, J 4 1 4� 'd�'�'�j 'r�li'I 4 S644O.4J crsft Rcr�,3h6� fl1� l Facility/Owner Name Facility lD#(if applicable) Lcsft• I ' ft. it fr +'f 1 i 4,,...r MT en lid) kc4n4po/13, /e tr"r '/ f mot. ays-ft- mire Ei?oc kk Physical Address,City,and Zip /� • ft. ft. (! ✓,� nOid4/ La_ 9Q 4 /ti 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.Certification: N W / r. ��J 6.Is(are)the well(s)JPermanent or Temporary Si/of r rtified ell Contract Date B signing this form,I hereby c !IA that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: DYes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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: You may use the back of this page to provide additional well site details or well 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled: � � SUBMITTAL INSTRUCTIONS 7 9.Total well depth below land surface: (ft) 24a. For MI Wells: Submit this form within 30 days of completion of well For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following: 10.Static water level below top of casing: 40 ft. If water level is above casing,use"+' ( ) Division of Water Resources,Information Processing Unit, , 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 6 �^(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a 12.Well construction method: 1?�/9/`� 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: FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, / 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) 4 Method of test: Airlift 24c.For Water Supply&Injection 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. ' I Form GW-I North Carolina Department of Environmental Quali ty ry-Division of Water Resources Revised 2-22-2016