GW1--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