GW1--08069_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I i
Joseph Bailey
.s14i"sWATER4z0nS ,...:r ;:r . a s m � ,s tr.
Well Contractor Name FROM TO ""
DESCRIPTION
3271-A aS `. arli ft. /7GJ7;re Zoe
ft. ft.
NC Well Contractor Certification Number 4444
B&K Well Drilling Inc flc11121 cASTIV6fra�5iiiii T w44'OTHICKNES fiiip t iTTE AL <. si
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ✓� ft / / I ft 6.25 I 1°• SDR 21 PVC
ote /�-fie a3�/�// FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 11 I7 SCREEN':.,» r.�Fs,xac. r r:z * '�KtiV ,. '1;� fi�F.tt' , ,.' . wi
Agricultural FROM TO DIAMETER ii SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft ft. in.,
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single)
ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation18GR�t3IT,t' .*� ;;:iu xa.- '` r ^1r�-� axsr '�. x-4�E,..a.,:.z:'c. .. ;x�:; ry•_
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft /G p A A
Bariod Hope plug Pour ,(J�/Vij /�
Monitoring DRecovery ft. ft. i
Injection Well:
Aquifer Recharge QGroundwater Remediation ft ft.
Aquifer Storage and Recovery Salinity Barrier 9`SANril lt&, G'P CAC(MATERIAL
Ile)M ENT METHOD
x
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ,2b„riTITL311�tGS:>?G(atfact addtiranatslteeisi'.necessa IM '
i
FROM TO DESCRIPTION(color,hardness,so rock '�§ 3�,..
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 f. /O ft. ? type,grain size,etc.)
ACC, I'Sea
4.Date Well(s)Completed: /,3A2 3 Well ID# /Or, /0 ft. g�ft. 31.d ! s
5a.Well Location: . arft. t(a ft witai;idcoy/I,s'C4 fSvi J
R fdit/ Ill4 4co -ri/ /-arloci ird ft- go ft- rivi if,3/aL✓� .14aJief ii la rer
Facili /Owner Name V Facility I #(if applicable) L�' 0 ft. //O ft. CQl�; nz
/363 7 p/q /7 J. ,decay/al ,fr r`4: ,� /lb it 3o f'ft• Jam' I/*/2 c(k ,/ �T3
Physical Address,,dr City,and Zip /� ? c ft. ft.
.rr4dell Coe 10-31�;l 9 "21 RE 1ARlf3:,r s AMM ER fit £ . }1s
County Parcel Identification No.(PIN) ' 9 ,' o- .. 4 i r i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: +� ry r 7 r
(if well field,one latllong is sufficient) 22.Certi ation: : DEC 1 b `52 3
•
tij�
N W !d?�I"„ i�7 ?r;-�.�,;+e�: I/
6.Is(are)the wells) Permanent or Temporary ature of crtrfie ell n for3. Da
y signing this form,I her y eertjfr that the well's)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or EiNo ,with 15,4 NCAC 02C.0100 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. j'
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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 1
9.Total well depth below land surface: J OS. (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 tt 200'and 2@100')
construction to the following: i,
10.Static water level below top of casing:40 ft.
If water level is above casing,use"+ ( ) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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 Centrr,,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air lift 24c.For Water Supply&Infection Wells: In addition to sending the form to
136.Disinfection type: Chlor Tabs 1 1/0 Tabs the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to th 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