GW1--05501_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I;
1.Well Contractor Information:
Joseph Bailey .
.4.f AllIER'2ONEs ':.
WCiI Contractor Name FROM TO DESCRIPTION
3271-A 9Asft. / 00ft ", r.,;07 fezw
frNC Well Contractor Certification Number ! %O ft' / ft. � /3 C 7F /2
IS,OUTERCASING(for.mnlh-casedweils)OR'LTNER(if..ap Lcable}.?,:
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. kl ft. 6 1/4 ; in- SDR-21 PVC
Company Name
r j7 16.INNEWe GOR-:TUBI Gifgeitlierma tloseddo0)!i:1.:'� ._:. ::...
2.Well Construction Permit#: (.5 -47 45t/�,�6.,3 ?7 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:
17-:SCREEN..:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural • ❑Municipal/Public . ft ft. in.
❑Geothermal(Heating/Cooling Supply) t ential Water Supply(single)
ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
183E:GROUT . :;. ,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT*
Non-Water Supply Well: 0 ft 20 tt Bentonite Pour h ge f f fj0
❑Monitoring ❑Recovery ft ft
Injection Well: ft. ft.
' ❑Aquifer Recharge ❑Groundwater Rcmcdiation •
19 SAND/GRAVEL•PACK(dappllcable} .
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft i
❑Experimental Technology OSubsidence Control ft ft 1
❑Geothermal(Closed Loop) OTracer 2ti DRILLiNG:Et)G.attaclikaditiaitsheetatfii
❑Geothermal(Close g/Coolinlg�Retturn) se DOther(explain under#21 Remarks)-e FROM TO DESCRIPTION(color.hardness sofUrock type grain size,etc.)
4.Date Well(s)Completed: //'O9 27 Well iD# 161—//- ® ft �Q ft �� - S sail
/I//
� / o ft 3 tc i3rod,i/J s'a f l
5a.Well Location: /� ..J eft 0 ft 4 '6/13a..✓19Js/(
'/�,�!ncIi!/Li�!/I L U // iI AI�l(/ S[1 j U ft r.✓ft /'j✓ t!'/�eJ/4,. (2
Facility/OwocrNamc acilityiD#(ifapplicabld ft �/ ft ll J �leo��
f , L (�/� r]Q h �� oar G y7i r�, t.,.. :.�." J _
///� hdr�tL AYI�I a �r./ 0 ei��/11C,/YG- /PO'l I ft. ft �...► r..r t`..R it �~
Physical Add ,City,and Zip J ft ft.
/t U �/ ` !, (`L D
. ea. %(/rl f_ .2, l/v ::IL, ,: .. . ;4!. � 0 ':;r.
ounty Parcel identifrcattiion No.(PiN) lfif— ►-<: .r • ?,,. _ .; _i--
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Co`t yt1' t)y
Uttk
(if well field,one lat/long is sufficient) 22.Certi ation•
`�__// N W __zit
6.is(are)the well(s): b ermanent or OTemporary Sr a re of en fi ell Con for Dat��,� y signing is form.I hereby ce in,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or EIl 6 114 NCAC 02C.0100 or 15 AC 02C..0200 Well Construction Standards and that a copy '
If this is a repair•fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under,i21 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 construction info
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:9.Total well depth below land surface: 07//��6) t
(ft.) 24.SUBMITTAL INSTRUCTIONS
For mtdtiple wells list all depths,jdii ferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
If[care,level is above casing,use"+" (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/18 (in) 24b.For Injection Wells:Copy to;DWR,Underground Injection Control(lUC)
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
(l
(i.ea.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 o!er 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)
,, Method of test:
6bei Air Lift Permit Program,1611 MSC,Raleigh;NC 27699-1611
Tabs
13b.Disinfection type: Chlor. Amount: 1 1/2 Lbs
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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