GW1--01845_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: � ¢' ce "°'
1.Well Contractor Information:
Joseph Bailey
"14WATER ONES• a r.s o
Well Contractor Name FROM TO ..
DESCRI 1,ON
3271-A it 0 ft. /trIL pfej i4e,, 2dO
NC Well Contractor Certification Number ft ft.
B&K Well Drilling Inc 451"f0eASDialf° ° agkvTrIIfi , )
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' I /?Gft 6.25 in. }SDR 21 PVC
u p
/]�✓�3 (�7/ .FROM VEVC.Y SING;;OI E ,.: .. *-.. E 4:
2.Well Construction Permit#: tS( ET � S 1 4 '
FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction pernri i.e.UI ,County,State,Variance,ere.) ft. ft in.
3.Well Use(check well use): ft ft. in.
,,
Water Supply Well: .1?:SGREENS,.uu , -d ''f<..r, x 4 i_ t a W
IV
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public
ft ft. in.
Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single)
ft ft in.
Industrial/Commercial E3Residential Water Supply(shared)
Irrigation & G120tI _ sr,` a
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft f� i/A
Bariod Hope plug Pour J
Monitoring E3Recovery ft
Injection Well: ft.
Aquifer Recharge E3Groundwater Remediation ft. - ft
Aquifer Storage and Recovery Salinity Barrier 449?.: / PACK`CIEapffeStile)z"r �� , : _ § #VAl ;a
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ,Zfl D GXQO fad ad � �o
Geothermal )a ., -g
(Heating/Cooling Return)/� Other(explain underT#21 Remarks) FROM TO DESCR ION(Cr,olo hardness,soiVrock type,gram size,eta)
4.Date Well(s)Completed: 42 % Q�� Well ID#LOT-
93 ft. JS• ft i slot / Car•S '
44 5a.Well
lll Location: 4 G ft Yo ft. //�Row/w/ S id di'I
/14�/wc/ e5 4�fTf+ /fkC/i wPJ/j�rf ft. g�ft f ,.Sh /Yi'+�1„...� s.
Facility/Owner/Name + Facility ID#(if applicable) Ift //eft r .a// a� ; �/Rah/,�/•'tV�/ 0f {Jc t {J ft. ` 't7
Physical Address,City,and Zip
� f� 8� 7 t �3�. � �/s�l� ",
Ltkl&4 3/q07
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r-^ �-, ;�`�+tom+ •.,
(if well field,one laUsufficient)
long is 22.Certif lion: 1 E IL.,..:L." t L.LI
_ 4N W AK222024
a�
6.Is(are)the well(s) Permanent or Temporary Si of rtifie Well C n or Ire
1 ,t� i'i'ew.;�i1?
signing this form,I hereb r/that this weilfs)s were)constructed in accordance
7.Is this a repair to an existing well: ljYes or EiNo ith 1.5.1 NCAC 02C.0100 or 15,4 NCAC ok".if2ri0- el onstruction 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:
dac 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 Ifdifferent(example-3@200'and 2@100')
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.) i ;
24b.For Iniection 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,misty,cable,direct push,etc.) construction to the following:
I I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /a oil Method of test: Air lift 24c.For Water Supply&Iniection 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