GW1--04251_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey I&WATERZONES
FROM TO DESCR ON
Well Contractor Name ft / ft
3271-A
ft fL
NC Well Contractor Certification Number I&OUTER CASING`for mNti awed wells OR tIIVI rba lidtbk
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name OF ft. I PSI f 61/4 in.
" SDR-21 IPVC
3�GS'31 16.INNER CASING ORTUSHIG
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List al/applicable well construction permits(i.e.UIC,County,State. Variance,etc.) f. ft. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural ❑Muni /Public ft. R. in,
OGeothermal(Heating/Cooling Supply) srdential Water Supply(single) fL f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
❑i1T1 ation ❑Wei IS>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft Bentonite Pour N
❑Monitoring ORecovery ft ft.
injection Well: ft. fc
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK If
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage rt. fit. Its?
❑Experimental Technology ❑Subsidence Control ft. ft. T. 1t`
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach addidonalsheetsil
❑Geothermal(Hcatin Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soitf o k type,grain size,etc.
fL U ft. i 9k 8C,4 ✓q f01 l
4,Date Well(s)Completed: Well iD# Id ft. ftI
��� { �lOv 4
5a.Well Location: 70 ft. G ft S� wi
LgrtSt ���s _ Aloe V fL 1 0,l
ty Facility ( apP ) U ft. O ft t !i1 h 6 0
Fac dSi//Owner Name f- L // /(�'TD#Nf Ii(c�ablc��j `
V 1!n pc,✓ll�f lle 5e&f !J. \��Ie J6NSi 1tK i L ft �✓1� ` / e
Physical ,City.and Zip rn /'� ��t
&ha'a C.Q. P V a IL REMARKS
County Parcel identification 40.(PiN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: a i�A Op a
(if well field,one lat/long is sufficient) 22.Certi tion•
N W �� ay
6.Is(are)the well(s): Orr..nent or ❑Temporary S1 tore o enifie ell Con ctor Date
/ signing this form,I hereby cerrif,that the wells)was(were)canstntcted in arcorda ce with
7.Is this a repair to an existing well: ❑Yes or MAd !SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been pro•ided to the well owner
repair under=21 remarks section or at the back of this fornn.
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 construction info
construction•only i GW-i is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ;24 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple welis list all depths iiidii ferent(example-3Q 00'and 2@ 100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: (ft.) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter:6 1/18 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh.NC 27699-1636
12.Well construction method:Air Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) t .2— Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type. Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 6-6-201 R