GW1--06517_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD GW-1 '�
For Internal Use Only: +. f
1.Well Contractor Information:
Joseph Bailey
I
Well Contractor Name z ._, -A1ER NE •,I> l:s? . _z q n
p^ , i..,_.,.! d i 1{w ,� FROMDESCRIPTION
<�,„a,..,�s''_ x ' 6...`
3271-A �"TOEscR,
v.s® „fi L: • L_.,..,, f/D ft. f/ ,ft.
NC Well Contractor Certification Number 0 C T 1 S 2023 ft ft. I
B &K Well Drilling Inc 15 O�Rc ING(f murt al a e-)=aR mf abl$ , m�
�c f...�.7.-, ,+)r a FROM TO DIAMETER THICKNESS ��+�
Company Name 1'' �'-� UR ft. I /�� MATERIAL
�.c,•••. (/ fL 625 I SDR21
G.: ;ter In PVC
4el n
FROMNER.GAS'ING U11-1TTB1AM TTeot iiHr aG:ctosed=lS S 0 - : ;R,A!!-)
2.Well Construction Permit#: itePtia`r a0,1 3 —2 /630 FROM
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) /S ft. TO DIAMETERa DIAMETER THICKNESS MATERIAL
(/ 7 ft. q in.
3.Well Use(check well use): ft Sc!,yv �(��
ft. in.
Water Supply Well: 111.72SCREENs < x 05511,N t ., l 1 t
FROM TO � a.,;T ,L.'",n.^ �_;:°„w, u��:^x.TM� <'x
AgriculturalMunicipaUPublic DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
• Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single)
°IndustriaUCommercial ft • ft. to
Residential Water Supply(shared)
Irrigation XSGY2(fIiTm E. .:,' ,< r =;r- Sao rr.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
0 ft- 20 fL Bariod Hope plug Pour
°Monitoring °Recovery
Injection Well: V ft.
gAquifer Recharge °Groundwater Remediation ft ft
Aquifer Storage and Recovery Salinity Barrier 19.x`r iD/GRAF I pAGZ Ht aTERIAL I ; sx
FROM TO MATERIAL '�' '�»' •,"`�'�" '"�"��"'Aquifer Test OStormwater Drainage ft. ft EMPLACEMENT METHOD
Experimental Technology Subsidence Control
ft ft.
Geothermal(Closed Loop) °Tracer _ _
Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) • TO DE ou8lst ets eraeeenes,,soil/rock
size,
„t d
FROM TO DESCRIPTION(color,hardness,s
T ft.
fcr /7 type,grain size,eta)
4.Date Well(s)Completed: 0/r2//a Well ID# 'd/ /3 ft.
0 SQ!1 f
S� ,�D ft / rla.,rJ fGti�/
Sa.Well Location: .1..... .10 it. PO ft )'/a j, $4•74f ) /
•
• ,ycaD' 13&64i/7 �]T'//Afela✓GS� 4 ft. — ft i3f jam, /Facility/Oww,„,llr Name Facility #(if applicable) .rS ft A�ft G j I / 'z' J �0��
34'i 00.4 if"Ael,T I �• t� r ��c/
��o� /��T e �ft.
Physical Addrejs,City,and Zip &y fl'r�' ! Tr /ZoG
7"rede/f Ca . �/' /- y.l1:a1lA :,WR, ti..
County Q ���� � v. .a a ,Gam` i$ d
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 ` ;
5 ' 1 ,,23
6.Is(are)the well(s)0Permanent . or EITemporary gnature Certi cd Well ntractor ,
Date
d in accordance
7.Is this a repair to an existing well: °Yes or D3No withf15A NCAC 02C.01 0 or ISAtNCAC 02C.0200that hie well(s)Wel Constructions Standards and that a
If this is a repair,fill out kriown 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 details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q5
For multiple wells list all depths rfdtfferent(example-3@200'and 2@I00� ons c
For For MI Wells: Submit this fotin within 30 days of completion of well
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
12.Well construction method: Rotary 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) /41 ae Method of test: Air lift 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs" the address(es) above, also submit ones copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/0 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