GW1--04570_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD (GW-1) For In ernal Use Only:/
1.Well Contractor Information:
i
Joseph Bailey :14.VttATER`ZO s it ta,. ,a.:,;a,
Well Contractor Name FROM TO DESCRIPTION
3271-A f rft. . i) ft.ft. SO4S f r-G1vdic Zoee.-
NC Well Contractor Certification Number ;.15:OUTER:CASING(far niultt cased_avells),OR LINER(lfuipp licable)s
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. kr ft. 11/_ J O(�' in. ®Q lit�A
^f 3 � :16.INNER CASING ORTUBING(geatkermal`closed loop);, ... - ,
2.Well Construction Permit#: u FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,..Yarignee„etc) r.,,-,. ft. ft. in.
3.Well Use(check well use): . —'',.•,'L_.a re' ,,,J,,,. ft. ft. in.
Water Supply Well: (� ''17.S EN� ', ..� . ...., _ _ .... . .
14�l1 1 / ZO23 FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J IAgricultural DMunicipal/l1ublib ft ft. in.
it Geothermal(Heating/Cooling Supply) EgResi ftj}al:yaten 5t1pp1y0iii'g'1 L:I l a. ft. ft. in.
al Industrial/Commercial OResidential Ws 54tpp1R`s1iared) ,„ I
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Benote Pour de 4'j !h -
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
',Aquifer Recharge Groundwater Remediation
b 19.SAND/GRAVEL PACK(If applfcable) ,'r �.h
Jr Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
jr i Aquifer Test D Stormwater Drainage ft. ft.
ill Experimental Technology 0Subsidence Control ft. ft.
It Geothermal(Closed Loop) Tracer 20IDRILLINGrLOG(attach additional sheetslfnecessary)^ ,.,_,,,;_.,.>j ='
:-- FROM TO DESCRIPTION(color,hardness,sollfrock type,grain size,etc.)
;Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) r1 ft. �� ft. t C ef
/_ V • JO[
4.Date Well(s)Completed: �,/t3 Well ID# l d r/0 /0 ft. a(ft. /�_ n sir I
5a.Well Location: ffff ��ft. 5' /j_� //a-:::
�W"s� r� Q/ry �
/ rr/(t. /1 �4Facility/Owneeryr✓✓N,,ame FacilitAy ID##(if applicable) / ft. ft. (l'
&vm I1t4JjD, kQnn f/oIl tW R I ft. ft.
ft. ft.
Physical Address,City,and Zip
2L EMARKStti? ,-€a V]i. ... _ _,
County Parcel Identification No.(PIN) 4)?l1 _ W06
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifications
N W ` --4 9
6.Is(are)the well(s) Permanent or Temporary Sig tore Cc d Weil .nhactor Da
B signing this form,I,H ebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or FNo with 15A NCAC 02C.0 IO 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
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
9.Total well depth below land surface: 0.�t (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
n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /I b''fY construction to the following: , ;
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
1 FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 1 f Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Tabs completion of well construction to;the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016