GW1--00455_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
Well Contractor Name FROM TO DESCRIPTION
3271-A !GO ft. 141 ft. .Siee/�I44rgre=file
3‘,0NC Well Contractor Certification Number ft 3 j1 it /I,' �I �� .��.»G
Sic011TERCASING.(foriiiiillf-taslid,Wells)°<O11iNEI((iftipp able); 3., ,S;Mi
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
® it g ft. 6.25 I 1° SDR 21 PVC
Company Name ///�/ n`19 363,
/� O sk
(/.�� �LvI� — tJ✓ gl iN tEIMASIN Miali$1?0 eatlietanal closedRo'WIZMI 3.s .-a ,
2.Well Construction Permit#: " FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft. ft. j in.
Water Supply Well:
.< VSL,REEN. ia; ....riaTkli.sli >.a £"z,>Agli „' - , ,.,.z..0`
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) pgResidential Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) $.GR II'ix ,; a" Myµ
a,..,:'w3 s...e, .� _� eg.,im:e€r.e«mmx-"t_:-=3, m,es_49v'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft- 20 ft Bariod Hope plug Pour /6,--- isom
Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ()Groundwater Remediation
l99i• ANDDGRA`ZTLPAETC(if'applicahle),,,.e...,.: t<f„a_ -,•'"T
Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage ft. ft.
•
Experimental Technology °Subsidence Control ft. ft. ,
Geothermal(Closed Loop) OTracer 21)l.'DRILLING T i1G(attacliaddttao'n"a heelsaf'neeniiiii , M" 3 ,
Geothermal(Heating/Cooling Return) FROM _TO DESC_RIP"ION(color hardness,soil/rock type,grain size,etc.)
( g/ gr Other(explain under#21QRemarks) ft /� ft. if
4.Date Well(s)Completed: / "//'3 Well ID# .47'3 )R. !3 //
ft. U ft. r
� S61 l
5a.:Sgll Location: [� 0 ft. / �ft. yebitgco 5. j��/ /
ke 5 i hoof r (D ft 0 ft i?eJ.3h it �n S ��JJ��% $dV/
Facility/Owner Name Facili ID#(if applicable) ft. 96 ft. G car :Aviv/
S1 sT s ia. fide Roll) 777SLL���``�U''' ft /EUft, %Gk
Y p � //U it. ..0 Rock
Physical Address,City, Zi
XrekiI /�/i , 0 i�3/x =?.r.af1�+14/FA lie iU:">';� ,'"<,zgK. 5;?v. :W:TA.M%'.ire' ,M.:z x;V;D"ma's.,.. ,', '.y
County CO,` Parcel Identification No.(PIN) 4,id ir*e e.1e 2'fc :7)J 4!`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `~+�'" `"�J°"'
(if well field,one lat/long is sufficient) 22.Certifcation: ;. Z. b-`�LZ n V tij
N W JAN1620244a S7
i
6.Is are the wells Permanent or Tern ora i hue o eni icd Wei ntractorInti J ftrf��;io., �r-w �� : Date
B signing this form,1 herehv certify that'the weU SJry f(,we, con.trtictea in accordance
7.Is this a repair to an existing well: ()Yes or EiNo with 15A NCAC 02C.0100 or ISA 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: J (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 2t0,1001 construction to the following: 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 Ceniter,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 iform 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /0 I PI Method of test: Air lift 24c.For Water Supply&Infection 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 to the'county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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