GW1--01835_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) ?!
For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
Well Contractor Name FROM TO DESCRIPTION
3271-A 5ft. 9 g ft _Cti4.411 river-ere 4-e.
NC Well Contractor Certification Number c2.1.4 ft 1 ft'
JA_�l I ./�/J
35 OU'TERteA Cr(i'or m°Itficaae'O r re��B&K Well Drilling Incrte
FROM TO =0T•� Z ap I
MATERIAL H--a
DIAMETER THICKNESS MATERIAL
Company Name 0 ft CI... ft. 1 6.25 ' I in'
� /� I SDP 21 PVC
2.Well Construction Permit#: c t s P '1 ER C IN—G OR">TUBING Ct;'ebtbeli'mdf'ciosl*Iiiii .=- ;.
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft.
ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ZIZSCREEN ; r -T .3-I ; ,t S* .,r..
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural oMunicipal/Public
ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) '
DlndustriaVCommercial ft ft in.
Residential Water Supply(shared) --$1---- Tf - - — .
obligation ., ,• .. s
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft
Bariod Hope plug Pour Q� S i l�l
Injection Well: ry ft. ft /y/V
Aquifer Recharge Groundwater Remediation ft ft
Aquifer Storage and Recovery Salinity Barrier t-19'S` 7GRA P`t (MAT irf1.-. 1 '�' ' "`T1 1
FROM TO MATERIAL „EMPLACEMENTMETHOD �e.Aquifer Test DStormwater Drainage ft. ft
°Experimental Technology °Subsidence Control g• g_
Geothermal(Closed Loop) OTracer
.:1,i1.DI2I1.'DINGE (attachsdd iiiii s7:s"lt'ecisiif aecessarQ ,,_4 = W"
(Geothermal(Heating/Cooling DESCRIPTION(color,hardness,soiVrack
g/ g Return) Other(explain under#21 Remarks) type,grain size,etc.)
Coolie FROM TO
0 ft i g ft. rf{d .s6.1
4.Date Well(s)Completed:I/104 Well ID# 1 ft ft. wri Sad
/
5a.Well Location: 3 it. Sb it If eamir. ".4.sgJ7j 5cr/
iirIhd 40/4 /9d le ft / Sft
Facility/Owner Name rr (Q GT/'C� /�tl i✓ 7 S��l �j' J
/' J Facility ID#(if applicable) y 4�ft. ISft. Meet s/ e ,TOG rq`
a)AS" am be e,(/?a' C/ .k0J A/C.c72t 3 8 ft a'l.it ',1�,`r(A�i,' t7AI r?csck
Physical Address,City,and Zip g
/)di,✓aT to. 5 ' 0.39
ts3i>�2E14IA7tf�.4 �r � �s� �,� , s x
Coon Parcel Identification No.(PIN) 1 . ' .s k n i��r 11yi 11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) g MAR n frj G 2074
22.Certi ation: �AA
1
N
W -Yini ,-071 Pr:`^.r...,:n5 L . 0 0)9
6.Is(are)the well(s)01Permanent or °Temporary Si tore of C ified ell Contractor Da
•signing this form,I hereby certi t at the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or EiNo ith I54 NCAC 02C.0100 or 15A C 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 details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
.drilled:
kr d SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days
For multiple wells list all depths ifdeerent(example-3@200'and 2@100) of completion of well
construction to the following:
10.Static water level below top of casing:40
If water level is above casing,use"+^ (ft.) 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 Center',Raleigh,NC 27699-1636
13a.Yield(gpm) /O ebd Method of test: Air lift 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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