GW1--06513_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i ,
Joseph Bailey " " ` 4W. IO s _
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'I.'!`�::.rp FROM TO fL._:a.:D C �`';s .. `. �'ac.:.�'^s3« `, _w.:-
PTION
3271Well ntractorName 3 if`r 40 Ai fi4A/fre Ztf;
3271-A OCT 1 ;i 2023 fL ft. k
NC Well Contractor Certification Number i,WO R,CAUNO,(tob Via' * fl jdlt} trajbXe) „w"' ,� `.I(
B&K Well Drilling Inc if`:,h.:...:l I':,,..,7,+..p.2, •t x:i FROM TO DIAMETER THICKNESS MATERIAL
t
rS c- `.t.:"0.Tj 0 ft. diveid ft. 6 25 in SDR 21 PVC
Company Name , ORSIt: t 114 R,k'1IMINalfa ltetmai;,closeitaafer M', s.-,WI FX:
'/ 2"03�
2.Well Construction Permit#: ��b�2�_ O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructionpermits(i.e.UIC,County,State.Variance,etc.) // in.
'L ,t ,/
PP j� ft. 9�/ ft � �(r?�f/ I�.
{/ ft. ft • in.
3.Well Use(check well use):
IT SL REENImel r �.I.« ili 0 "., 'M s . 4
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
BAgricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft. ft. in.
QIndustriallCommercial E3Residential Water Supply(shared) yti.;tilto , o - 45n n w , - R „ -, ;
Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft• Bariod Hope plug Pour
Monitoring Recovery D ft
9 ft. /i�,� mix 4 Dc //A3# c
njection Well:i /� / J/
Aquifer Recharge Groundwater Remediation 0
de ��
:j9:Si1PWIG12i1L?ELP+ (ffapP
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft
Experimental Technology Et Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 30 DRIL'EIiY t3Gr(3ttacfiallditigil als'ltects uneeessaty)'4a...ate ' = M«
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
jGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 6 ft. t j? d.5 ai
//aJ2
4.Date Well(s)Completed: 1 J Well ID# Lar-2 y ij_ft* 3 raw?, ail
ft. ft- Y/tY iati ern 54 J7 i'
5a.Well Location: � G a /
3111 Otriw O/7f7dl2'f If' a/nAric 4ft �Uft' •/ s�y54i(
r FacilityID#(if applicable) (t ft yo ft. 5 /JSz
Facility/Owner Name PP ) O U cast- ��� //«
( W/D revue" Li;ice%o7 Ave a8o7� Sv ft. c aJ t V�,�I c em.k.
Physical Address,City,and Zip fL ft.
Zfh-edA CO. /5)oi Ill _ t .W: g_ A .
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 ✓ f '2
Si o C ifie. ^e Co .•cf/"
6.Is(are)the well(s)JIPermanent or Temporary Date
signing this form.1 hereb c:,'ibz that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EgNo with ISA 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 Itothe 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S (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@I00') construction to the following:
i
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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) '(� Method of test: Air lift 24c.For Water Snmily&Injection Wells: In addition to sending the form to
V the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chior Tabs Amount: 1 1/0 Tabs 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