GW1--00458_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD (GW-1) Forr Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14izWATERZONEs .. j. � . .,.. _ ,.,.;... 1.
Well Contractor Name FROM TO DESCRIPT ON
3271-A tt{t,rc 444 ft. 1t4s�%re 20�
ft. ft. 1
NC Well Contractor Certification Number '
'4.5 01ITERCASING(formidti-cuseifivella).ORLINtRtifin Ileatile).,.. .
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. . /4 ft. 6.25 in' SDR 21 . PVC
Company Name
/1, ,#e e q�®�� -16i&INNER CASING ORS TUBING:(geothermal closed=lgbpy t .� ' ,,ri4
2.Well Construction Permit#: //W C� (� FROM TO DIAMETER THICKNESS MATERIAL
I�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) }� ft. Po 9./ ft. all in. c fo mic.
3.Well Use(check well use): ft. 7 ft. in. r!
Water Supply Well: FROM�EE To ?< .. `DIAMETER 3 .,.. : . ::,. . ..-w..,
R
0Agricultural DMunicipal/Public ft. ft. ,in. SLOT SIZE THICKNESS MATERIAL
°Geothermal(Heating/Cooling Supply) EjResidential Water Supply(single) ft, ft. 'in.
°Industrial/Commercial DResidentiarafe ,Supp�A.(shar'ed;i" �8 ROUT. , _wI, �. ii
$''a a 4., �.i; !1 4 :.. E. AMOUNT
..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL Buried Hope plugPour
0 Monitoring Recovery
JAN 1 1; 202��
Injection Well: ft. 99 ft. 4947 Mix la$!,•r i
rtP li it Y rrC,*47.10 J ic.A ft. ft. /v >1 !'°/
DAquifer Recharge DGroundwfcr keine i ' r r 9�
A uifer Storage and Recovery Salini Barrier �l a 19 iSAND/GRAVEL`PACK(ifapplicable)
q g ery tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. '
QExperimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer ,20=DRILIANG LOG(atta ii addtdonal'sheets'if te�sstirg),,,, .:.
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock tlpe grain size eta)
L/ 6 ft. �,art. cdso,1003
4.Date Well(s)Completed: Well ID# $7T.Z 9 ! 5'1t• 3 rue, Ovi
5a.Well Location: S''''ft. 4® ft. !le/4 ///cccdddro, 5 77/
On id/ Q Gn4�6e1D 2 di/Pi ®ft. aft. er;/s4s y50a(
Facility/Owner Name � /iFacility 1Dil(if applicable) 9.0 ft. (;® ft. 5 e
� Ta
a�� ue.: ;�Li k/o'NC a5G5� FO ft. �' -ft. '{Reek
Physical Address,City,and Zip �y ;21c)REM ft. ft. '
ys/
L`/) . o% CO. /7/ a R/ES .r- - ,.._.:Z _ _7, nR
County Parcel Identification No.(PIN) - i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: y
N W I / ' ifs { �RsT
6.Is(are)the well(s) JPermanent or °Temporary Si o C ifie. a Co .c Date
signing this form,I herebti c t fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or pgNo with I5A NCAC 02C.0100 or A 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 I GW-I 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: (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@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 •
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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Services Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Skil Method of test: Air lift 24c.For Water Supply&Infection Wells: In addition to sending the form to
Chlor Tabs 1 1/0 Tabs the address(es) above, also submit one copy of this form within 30 days of
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
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