GW1--06524_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Joseph Bailey ,14.wATERizol
Well Contractor Name '--"{ a„ /.,t—, FRJO�/M�/`' TO DES[C�RIPPTTION N �f,/�
3271-A •c.�\..p A.....t r1g/r". / -lJ /lib V ntep// ri�IV `6 e
ft ft 1 1
NC Well Contractor Certification Number O C T 1 S 2023 jS,;,p !rEg_tAgII O,(farrmw-tasetl ofiyOH IIagR(ap 7iriule) :�` ,
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
I''..V' l^._ • .'..•,.,;.,,.;r,14 laid 0
ft 40 1ft. 6.25 in. SDR21 PVC
Company Name ^^ec n %t�C:Plop i FROM TODIAMETER THICKNESS*a --�-dx. g `
2.Well Construction Permit#: W 14 a Q00—t1(tt(F NO=D ME � �� S MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
3.Well Use(check well use): ft I in.
TA/,SCREEN ,as-lev3 ,.0 . ;,.,,`a -.s $aw .mv;',z _isa
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural DMunicipal/Public ft. ft. i>.
°Geothermal(Heating/Cooling Supply) Elatesidential Water Supply(single) ft. ft. in,
°Industrial/Commercial °Residential Water Supply(shared) 18 0ym.. ,:;;,,. Fo ; r. {;_ ;, _z ..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft. Bariod Hope plug Pour 0Zej IA
°Monitoring °Recovery ft. ft. ill
Injection Well: ft. ft.
Aquifer Recharge °Groundwater Remediation
;. 7 SAND1G1tAVXE'rkCKt( apPllc`able) I:..„ % - €5 I f _ _ v ' ..<
°Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft. I
Experimental Technology ()Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer .,.20si1?1tIL1s11+fG;1QG:(a[taclidili6onals"heets<ifuecessary) .., ` J'
FROM TO DESCR lON(color,hardness,soilfrock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) Q ft. /v ft. Rtl
dstui
4.Date Well(s)Completed: £'a//a3 Well ID# li/r 1 Q D' *?C" agt°4f! S07/ `
5a.Well oration: / a(ft. fr ft. e/�0�✓ /lfi .S S�f
l..e1 C(ytr ke A;� �Marb,or l9 L Jr f n� /S/r i � stiiiir
,
Faci ity/Owner Name Facility ID#(if applicable) $3 Q � /5(�6 k d-S 91104 .�1
Phy/69 /�II'v//q ff /yla sl�iic,�/G.a�i/t ) oft. �,rft. ;sof1Rdek i/. &
sical Ad ss,City,and Zip , 1�t !/�t `�`r q 7J/'' ICO�i/�
-21e R1 IrIAR1{S` i t all F �rc a .
t,ie f c . 04fr-95- 9 5 _ a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certifrca' n: 1
j
N W 1 /
6.Is(are)the well(s)01Permanent or Temporary Sr of ifi a!Contactor Date
signing this form,1 hereby ce ' that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EgNo with 15A NCAC 02C.0100 or 15 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: O.6� (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: I
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
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
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 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 1/0 Tabs completion of well construction tofthe county health department of the county
where constructed. .
I ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016