GW1--00453_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Joseph Bailey .i14:wATERzoNEs q
Well Contractor Name FROM TO DESCRIPTION
3271-A • //0 ft 1/�2 ft, " o v 24-C2o
ft. ft 1
NC Well Contractor Certification Number
1%'Q17TEICCASING(formoth-cased ii.114OR1!INElt ifg "Hcatile) ,', ? ;;
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name ® ft. 6,'ft. / Ast in. GdR a/`j_R1 �/
/4 A :16.-I1V�tER'CASTNG QRsZ"IJB(FNG'(eothermaiJetosed,loup) t .: . ,? -.
2.Well Construction Permit#: .. `1 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 SappI Well: T ,,.�,` nISCREEN . , , .,A....,;;,i , s. �,. ,.. ;i �,. ��,.;,
,3
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) ggi Residential Water Supply(single) ft. ft. in.
°Industrial/Commercial DResidential Water Supply(shared) )18 GROiT1 „'014,,... i=, r
I' IITIgation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft• Benote I Pour J4),3, `/A
Monitoring Recovery ft. ft. �•/
Injection Well: ft. ft.
°Aquifer Recharge ()Groundwater Remediation '
©IAquifer Storage and Recovery Salini Barrier 19.;SAND/GRAVELPACIC(tf applicable), _ . -_. 2 ,.r.i<3,a .,,m
ty FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test °StormwaterDrainage ft. ft. 1.
°Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) ()Tracer .20:'DRILLING,I.OG'(ait"achsdditiuualsheetiiif uecessarj)a,.,
Geothermal(Heating/Cooling Retum) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
( g/ g °Other(explain under#21 Remarks) ft. ft. !/
•
ie
/6150/
4.Date Well(s)Completed: 4.Qs9`�3 Well ID# ‘7..5Z of ft. gx ft ea'w.ii qai ter
5a.Well Location: /� ^? ft, ,/io ft, I e64,, I i s�,�Lo,5-61
rt(!J k L to t'Gf L�r L 1 it Cto ft. 0 ft. r �9./ s IItt99 S.0"0vJ' e�
Facility/Owner Name / @ Facility ID#(if applicable) 0 ft. 4 ft. �,G/may_,_/2044
/7a &� Fri e 5 i • ido tddie,Ai l/� Ts' ft. 4 . '�j7 ReCk
Physical Addrf ss,Citd Zip ft. ft •
- erdeiI Co_ 44dq- y?.-6,14 r2�:�sq a _�.. A ,A
ounty Parcel Identification No.(PIN) ' ' `r'T•�- 7+'', !C.0
-,1,• o• s. a...a h.....0 0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J�� 6 �O�4
(if well field,one lat/long is sufficient) 22.Certification: 1
•
N W / / 19for s('..ifori Pic-cze rg V3P d 3
6.Is(are)the well(s)0Permanent or OTemporary
Si ure of ni e. f ell Conn.ctor u °axf�L Date
B signing this form, I her,,,(cc,t that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or EiNo with 15A NCAC 02C.0100.r 1SA 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 tti the well owner.
repair under#2l remarks section or on the back of this form. I.
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: Cr�iJ�j i (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdifferent(example-3@200'and 2@I00') construction to the following:
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
61/8
11.Borehole diameter: (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: Ri 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) ! Me Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1t2 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