GW1--04564_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
Joseph Bailey 14;wATER`z NEs, i,. . .w , ..m..;7.z.,.a;i_?P.V.,; . ,,,. ..,..i..
Well Contractor Name FROM TO DESCRIPTION
3271-A East i aX' Si774//firev�tj�2_� q„e2ax.
i'cNC Well Contractor Certification Number ft' 3 9 I ft 5 N O fae/ -• ��e
45:0111 aRCASING;(t'oi•; u1tL-cssed wells}'OR`LIl!f RAffii p aiiIiile)k ,u r'. ,„i4
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name • 9�y9, 0 ft. $ft. /'1 -- to C# a i //r7�r
L,O n- ! /11 lFS INNEA%CASINO`ORTUB[DIAMETER
K:geotheiiiii ewaina iiiI .'`P ER :
2.Well Construction Permit#: r FROM TO DIAE THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
tscREENa. _ 2_k „ .aN 'I .x.M:ni: v r.iI.:_$
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in
Industrial/Commercial E3 Residential Water Supply(shared) !&GROAT s a, i_;v a
Irrigation •^ ' �'''tq FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: `•v,ti„„ r.,ii o:' ti_- ° ,r 0 f. 20 ft Benote Pour 1�/F4_vj #P
Monitoring DRecovery . n(n1,1 1 ft. ft.
Injection Well: AI 1 t- LO't-i ft. ft.
Aquifer Recharge ()Groundwater Remedration_ 1.,,A
• r ';:: 19.SM4D/GRAY:EL=EAcK fa' ) , ay
Aquifer Storage and Recovery �$.trhriity$ e[ , r• FROM TO MATERIALe EMPLACEMENT METHOD k .
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology EtSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 2Q I RIi; IN LOG.(attaehadr]itaonal.shei?t Ifaecessaryt v_ a M '°g:* , Mir: _:
Geothermal(Heating/Cooling Retum) ()Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil rock type,grain size,etc.)
0 ft. , oft (14SO/ 7
4.Date Well(s)Completed: a��a3 Well ID# idr I? /0 ft. it)
ft. 3�wi soil
5a.Well Location: aft. a ft. yedo.,,8. •. 40914a I
Inisotm HoirieJ I e fr11cJc), i 7 rg �ft g ft. �L' Sandi //
Facility/Owner Name Facility ID#(if applicable) f0 ft. 7S ft Sef1 ner k
,PGs''A(Qs 4/1, Sal ��/b' am) ft. 4f (ft• Gran�Re-ck
/? ' 'iPhysical Address,City,and //���L//� `r I ft•
Dq „V a !`i! G (g .r 21 Rr Mr�RKS ` r ,.ti:,.n''.4_ o:�::seo,r*... a *'. `wy et+v,h+6 i:,i..�;:
unty 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: / 7
6.Is(are)the well(s) Permanent or Temporary Si tore of ertific ell Con ctor Date d
signing this form,I hereby cer/tfr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or jNo with I5A 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:' OctBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �`7 ` (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 Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ,rO74. construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) „]g/'Q/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. 1
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016