GW1--04566_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ��o" "
1.Well Contractor Information:
Joseph Bailey
w,CNPATERZONE ?r,__ ' ,I
Well Contractor Name FROM TO DESCRI ION
3271-A ill ft. /i� ft. ��J/r�;�,%1rr e,
ft. ft.
NC Well Contractor Certification Number
115:011 'ER CASINO'ffi multi-caie0e1107ORL3NER:fir` lialifelgtt B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name �� /a 4�
P Y `� ft. ®� ft. /v �� to O/ i .
/D A ����g/ 16:3NNERECASING.OIt'EUB!ING;(eebtltermat;closed=loopj _' + _s
2.Well Construction Permit#: 4/ FROM TO 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: 7:aSCREEN �., .a»...,z. ..a
Agricultural Munici a]/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
p ft. ft. in.
Geothermal(Heating/Cooling Supply) EDResidential Water Supply(single)
ft ft. in.
Industrial/Commercial OResidential Water Supply(shared) -:,
18.,
rm..GROIIT «` .. :;, r >. mY 1z vv -^:R ,i
IrrigationFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Senote' Pour r ♦ f„(r
g ()Recovery s fj�=a f
ecovery ft. ft. v
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft. 1(''' k 5 ni y , 1 e
Aquifer Storage and Recovery r'19:SAND'/GRAVELPAfZ£(rfapplicahle) a... ,,, ,-;,, ,
ry ()Salinity Barrier FROM TO MATERIAL tEMP EMENT METHOD
Aquifer Test QStormwater Drainage ft. ft. J I_L I _ L LL,,
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer Irt,, r s 1 c t t
20.7DRIii1:t 1011OG(aftacliadditioust'sheetiif' digit>;}):x':s .._ rs. ,, v t,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
/ 0 ft• ft. j`eAseja
4.Date Well(s)Completed: "3/-0�3 Wel1ID# `(37-5 !( ft. t6) ft. P ♦
5a.Well Location: 20 ft. ]/ft. %�J�^1 r �♦ e p .
�C/1Ij��YJ4,�/1It, �t!�.. fri "s?"a '�fL d i�tll��dlA��--�+�tf�..)�'%i1- �.�C�.Jift. ,-- g i -..e4 0�� /�Jti tl: rJ� ,
Facility/Owner Name Facilityapplicable) 25'ft• e" ft. • •e: /y
r ft. t ft. ▪ �`.7 r>.i: •• i,r,, ,,/
4,74'.54ec ill;rdre RL, -/i:s r i/ca-rsi%// q r J O if ; u�c .
Physical Address,City,and Zip I�%� ft. a,e t,
21:'RER'IARKs,,`,'`. . is,, r • `'1,, >,'.ter-"1r Ye'`-"'`.; .0; tig
`'ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific o
N W rr / ,--,
6.Is(are)the well(s)JPermanent or Temporary e of Ce ed el ontractor '' Date
By signing this form,I hereby cent tiu t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or FiNo 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:'
f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /u'
2@100) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ljd Brent(example-3@200'and
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,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
"� above,also submit one copydaysp
/ O/tify� of this form within 30 of completion of well
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) d� construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
/f�,ff 1636 Mail Service Center,Raleigh,NC 27699-1636
® 6/)A4
13a.Yield(gpm) Method of test: Airlift 24c. Water up Inj W aenrm
Chlor Tabs tl2 Tabs the addresFor Wsest) aSboveply, also&s submitection oneells:copyIn of thisddition formto s withinding 30the daysfo ofto
13b.Disinfection type: Amount: completion of well construction to'the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016