GW1--08066_Well Construction - GW1_20231215

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information: I ,
`Joseph Bailey zQNFs1. '
14'FVAta'R:
Well Contractor Name FROM TO - DESCRIPTION
3271-A 160fa /io! ft. ..cirSf rferUre. totolge
NC Well Contractor Certification Number 4.P"f. j 1I f. h %e�ce an
.15 UUTIER:CASING(foi ii811i- sedyvels)ORIANER:l p liccable)=
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
fL 6.25 In• SDR 21 PVC
Company Name ,-I NER'CASING:OR TUBING'{geotheititel clost d atiop)[a
�, -(aa�� �4® MATERIAL
.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATE
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: 1VSCREEN ".' _.. ., , .< :E• ,.1
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural °Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. • ft. in.
0Industrial/Commercial °Residential Water Supply(shared) :18 CROUTw w .xs .'
(Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Bariod Hope plug Pour d9 at,.S.h/
Monitoring °Recovery ft. ft.
Injection Well:
Aquifer Recharge °Groundwater Rcmediation ft. ft.
49 SAND/GRAVEL PA6K(if applicable) , ,•.,;, .. .:; ... .::; ..;:
Aquifer Storage and Recovery °Salinity Barrier FROM , TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test DStormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20:JDR1LtIN( L'OG(attacliadditiouaislieets fnecessary)'<'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. /fil ft I Re sail
4.Date Well(s)Completed:ID-V Well ID# �_oT,q hJff ft. t' ira Y I
5a.Well Location: 3 S'ft• 70 ft-!
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f-5`l l riel/,1 S opeitt/�jjr/
ed,�1dg Iv 16. ,�w�t?. Oft. ( ` 5 o d /
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Facility/Owner Name Facility ID#(if ap 'cable) cc"ft. /, ) ft.l S®.i /pec!
/34 Gl/;Iha rrer Affesd1/r,MM� rlr 1®0 ft. 5al6ddI.tt•, 6-r4,4;/ arks`
Physical Address,City,and Zip p L // ft. ft.
2 iJe I! ea, 1 `Sp9"oosi 21:REMARKS = >
County Parcel Identification No.(PIN) s * ' • -'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) / DE C 1
22.Certifi lion: 20C3
n
6.Is(are)the well(s) Permanent or Temporary Si 10 lure o cnifi ell ,':ctor (3iw{; 'F J; Dat �6
:7'signing this form,I here y certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or MNo with 15A 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. Youmay also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: )15j/ (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifTerent(example-3@200'and 2@100') construction to the folloing:
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 Infection 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.)
Division of Water RI sources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) pcairn Method of test: Air lift 24c.For Water Supple±l&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs 1 1/0 Tabs
13b.Disinfection type: Amount: 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