GW1--04631_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 1tiNFATER=ZONES :'i ,. - n n M s
tagM
Well Contractor Name FROM TO DESCRIPTION
3271-A Pic".
PP) ft. /✓I f v1UJL'.s
NC Well Contractor Certification Number 1• OU f t. SI a•fL sysim'�r ram/ (If �e)
15:OUTER CASING(itir;�nitkiii'e CF.W ells}IOR^LIM-,fiEAliti ciible) a i.:?„3 '
B &K Well Drilling Inc
FROM TO DIAMETER�/ THICKNESS i MATERIAL
Company Name 0 ft• 40' ft. 6 a` to I C�� e�1 PVC
t°, O l3 - 1190V c JK Y(
16 1NNER'CASINO OR TUSIIYOlairthermikldtl�loup} A yxr it illN.2.Well Construction Permit#: 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.
alttE
Water Supply Well:-_ 7 CREEN x, o., row ��: a_. _ s .'..�t t ,,
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DMunicipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft ft in.
IndustriaUCommerciah E3Residenh aer-Supp1 (hared)
-r >18,GROIIT .: �+ I y r e
Irrigation � 'r .. i = ..` ___ _- =. �,_x�_.•,�,xtxa'..�s _
t &.�M
Non-Water Supply Well: i" 'A • :FROM TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
' '6`r ft. 20 ft• Benote Pour 12 41A s
Monitoring Recovery JIJI 1 %. 2fl2 ft ft. p(( f1
Injection Well:
Aquifer Recharge ft. ft.
qDGroundlAateriReifiedi`ajiblr..,,:az
1�,."�'t y• 11s SAND/GRAv*. ,,, IIEIC('da-..,ahle .,,.y: i r
Aquifer Storage and Recovery Salinity Barrier "' �1�._ V )• PL xa..,,.; „D - ''
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Q Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 2QrDRILLINp.r7G:(attschiiddttioaalsheetiifoercy y, ;-nG +,,,,k A ,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
� � D ft. 10 ft. R s' 7
4.Date Well(s)Completed:iga Well ID# / .) ft. 3 5-ft. �.-/� s,,
5a.Well Location: ����"" '3(ft. 60
ft' J441 arty S�,v i _
iljp Rill f
�o��f� t�� 0/f` '7V,�rft / '""% dfs ����7 /
Facility/Owner ame Facility ID#(if applica e) / /C ft. tt• � �/
l V�<s'rej's��j //!(jliarL'�Ul�/� N 4is li 9-61t. 3 .f9vrYr�ovk
Physical A ress,City,and Zip j ft ft
1r to/)( co, w2f:
16G6_5...0 K. / 'REIictiu w, ,x _ I �,;` .fx. . a.,t F:: },i
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient)
22.Certification:
N W
6.Is(are)the well(s) Permanent or Temporary Si use of a fled Well C n ctor Dat
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ElNo with 1SA 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:
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:
OFor All Wells: Submit this form within 30 days of completion of well
I
4a.
For multiple wells list all depths ifdifferent(example-3@2 'and 2@100) (ft.) ons c
construction to the following:
10.Static water level below top of casing:40
If water level is above casing,use (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
n
12.Well construction method: 1 74j-/ 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) 60M Method of test: Airlift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1/2 Tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016