GW1--01861_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
moWATErzoNlios , , ''i, l :41 r ,?x ice-:ate,+°s ir sigIV
Well Contractor Name FROM TO DESCRIPTION
3271-A /Waft- A/Aft sy o1/i F-ete�'r .40c
NC Well Contractor Certification Number 3 2 oft 3 a7 f �Y 94 a/rr'RG/we erne
x 15 OWIEIi CASING(faraiinit e�aev rwaiSS:OWL11W riti ' lej + ;s Z
K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name CO ft' 3in.ft. I 6.25 SDR 21 PVC
2.Well Construction Permit#: / /cie Sf6'13 iNER:CA:SING:OR'FTJBING(acetliiiii lclose�d4alpj E ,:<, ,, y ;;,,,;a,yh
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: ndr:SCR Nc�.:s ;SA x ..4x c .z,.w�.E-.0 ace,.z>: IFi .::e.�al ;°.
A CUItPP FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DMunicipal/Public ft. ft. in
OGeothermal(Heating/Cooling Supply) Elltesidential Water Supply(single)
ft B 1O
Industrial/Commercial
OResidential Water Supply(shared)
l &AfttPTaR:x �. R7 .Rf c _ �Y #s s.r.i,w sn
',Irrigation
- �` - � ��; .�.�
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. Bariod Hope plug Pour ` Y j�„ i
Monitoring Recovery ft. ft ^1.11,O
Injection Well: -
A infer Recharge ft ft.
qGroundwater Remediation
Aquifer Storage and Recovery349A D1GIi'AOEI.P'Af !(M ATERcable� r, -. AOMIN EM ;��i ?D
0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
®Experimental Technology DISubsidence Control ft ft.
DGeothermal(Closed Loop) DTracer .3=2D:DRILLING:ZOitiatal:s addtlioua'[Fsheet aeces k hR.m t f M,r M:
DESCRIPTION(color,hardness,FROM TO .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) soil/rock type,grain size,etc))
4.Date Well(s)Completed: l d/a©2 3 Well ID#_brig .3 '<ft. 3 S ft C r .. 77 Oil
5a.Well Location: r ft. ft. / ' 4 Sio cad
/?odjeYel , Oar' /I'.G 6S ft D it. bry f oFreRock
Facility/Owner Name I / ,,/ Facility ID#(ifC applicable))�� iv ft. J4f3ft 4�'� �f6G f
/l0/j rh'a SV44W /?d. �WJJr ei/y a ft ft. aC
Physical Address,n Ci and Zip r k C-OR# ft. ft.
GAQ// ' 5- �/
.G 0 r�r.//�''l3l4O/�',P22:ItENfiiiRKfi`�.eaVt M9RaqkW:xf :��Zlgi7A�.�,R,),pnrfz; Fa' g
County Parcel Identification No.(PIN) 7—'1 .e.,,1, p,�
.-.q y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �°�_-,i AI 1L)
(if well field,one lat/long is sufficient) 22.Certification:
N W /J,"`lad
6.Is(are)the well(s)13Permanent or Temporary Si of ied Cori ot Cti;av,+<;tiB G Da e
By igning this form,I hereby fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EiNo with 15A NCAC 02C.0100 or 1 A NCAC 02C.0200 Well Construction Standards and that a 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 onthe back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Iso i i Geothermal Wells having the same
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 1
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 tfdifferent(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 Resotrces,Information Processing Unit,
1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (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) car)/ Method of test: Air lift 24c.For Water Supply&Injection 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