GW1--04646_Well Construction - GW1_20230714

I Print Fgrm
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 'I4.WATERzoNEs . .. ,
FROM TO DESCRIPTION
Well Contractor Name
3271-A /W ft. Ma ft. Ss,9,11 rccTir .204
9 ysft. aloft. ivid icrfe re.2
NC&Well Contractor Certification Number 15.OUTER CASING(for multi-cased-wells)'ORLINERR`(ifap e)'. "'
B K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name nun U 0 ft. Sir ft. /.']s, in. ism 22' pit
G �_aai�d �//7 16.INNER CASING OR TUBING(geothermal closed-loop) '„:
2.Well Construction Permit#: �F d '7 r 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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Benote Pour /w&stslid
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge EtGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD R
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary) •' ..
FROM TO DESCRI P•ION(color,hardness,soh/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) in Other(explain under#21 Remarks)
it ft. ,O ft. / 54
4.Date Well(s)Completed:
,5/h1/a 3 Well ID# 10-0% /VU ft. 7 ft. roIS'I 50
5a.Well Location: a d ft. �S ft. eats j_/Q', n S441Ri50-,I
,r �„i m,4 /4w i,Lie #112 Ihr6acS0 50 ft. d S ft. by&L re" fa f f5 lc
Facility/Owner Name Facility Id#(if applicable) G ' ft. Q0$"ft. G'�jy(� 'o /`
136 I6r4Jof,'%.e la /A S r/le A/4 a�/4 ft. J ft. (1� 1
�rG Ur .
Physical Ad ess,City,and Zip ft. ft. . a`�.k- ttl '``p
• f Wdi Ca e 4I 4 10_
f �/5J 21. MARKS - �.._ ,. ,
County Parcel Identification No.(PIN)
JUL 1 i;. 7023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Iflf:::.".:;t.'^;1 P..": ;,,htz:;,t4 ytFx
(if well field,one lat/long is sufficient) 22.Certifl lion: Di r; .34,,:tty
N W S/11���3
6.Is(are)the well(s) Permanent or 0Temporary Si lure of citified Well Contra or Date
B signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EiNo with ISA NCAC 02C.0100 or ISA 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
r
9.Total well depth below land surface: 0S (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 cQ+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 Iniection 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: )?6Tir)f construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WE/ l
WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I)All Method of test: Airlift 24c.For Water Supply&Iniection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016