GW1--04567_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey ..14,WATERTZONEs ,
Well Contractor Name FROM TO DESCRIPTION
•
3271-A /.�. ' /S10- ivaI ra?'"e-zoi '
ft. ft.
NC Well Contractor Certification Number
'xS CtUTER CASING:(for;maltkited wells)OR•IIINER•; ir— `ble) (W
B &K Well Drilling Inc FROM LoreCI DIAMETER T/HIICCKKNESS M��L• ft. eV ft. d in J!f/(r ,Company Name
n {B • JA =T6 INNER.';GASING OR:TCIBING'i(.„--. „.,3osed'IuDjt).--
2.Well Construction Permit#: CL 35; 7 1 FROM TO DIAMETER THICKNESS MATERIAL e
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 �..__^�. . t WiW M'ZW:°; .'..
Agricultural MllnlCl al/PubliC FROM TO DIAMETER SLOT SIZE THICKNESS N MATERIAL
P ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
fG ft. in.
Industrial/Commercial ()Residential Water Supply(shared)
.--1&::GROUT. t ::" `- it : �s,,4-5 1_;
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 fn :••. ,, - j...-.: �Qpc}t/t/i
'°Ben,'ote' n z RONrq..,. VV
Monitoring Recovery ft. ft. f \�~^ �� /�
Injection Well: f. i U i 1 i. 2 023ft Aquifer Recharge ()Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier -19'SAND/6RAVEL'PACK(QLaPplleable) <s „': :t , t _,�„.`wr„ ,,
ty FROM TO In C111ATERIAE• '','VP, aEry1PI&CEMENTMETHOD
Aquifer Test 0Stormwater Drainage ft. ft. Dj,',•'C/i8'1';
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) inTracer 224 ffittEtINOI NG(attiiraiililititiaa""IsheetsiEaecessary):Y ,?.r :.
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTIO (color,harness,soil/rock type,grain size,etc.)
? ? /► it f^ ft. A e c'Say/
4.Date Well(s)Completed:171/721 Well ID# Ld/ 7 to ft. /l/ t• / rode O•,//
5a.Well Location: ,/ r . (/ t. 4 `/ / (r��50/7/^'!ngrlia,/ eis/Las //,9 9.0 ft. `�fs��7/ 2'wir Saito ei
Facility/Owner Name Facility ID#(if applicable) `' Y
(}t% ft. / IUft. ..5tT// Flevi7Qc,e
I/965 5401 AS IIJI?d Ss434�l ,Svc_a oN, //0 ft. _a?d sft a;r4orir1;,?o /<
Physical Address,City,and Zip ft. ft.
Raii/Q4 c a. go 74 21:iREDlARKs';2 h .._.. <<`?.',.• a, , _ ,t„„, * ..
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
6.Is(are)the well(s)0Permanent or OTemporary Si tore of rtifi ell Con c r Dat
signing is form,1 hereby t fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EiNo with 15A NCAC 02C.0100 or A 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 GeoprobefDPT 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:'
�O� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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
12.Well construction method: Ra/G/� 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:
Division of Water Resources,Underground Injection Control Program,FOR WATER SUPPLY WELLS ONLY:
//Q%'rll 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 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 • •
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016