GW1--05502_Well Construction - GW1_20240912

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
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1.Well Contractor Information: i
Joseph Bailey 14.WATER'ZONES ► 1
FROM TO DESCRIPTION
Well Contractor Name if. 1 it. I IX. .� I sf Gl�/e-.0Q40�
3271-ACit. ft. I I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Dcstble)
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
ft• r7 ft• 61/4 i' in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)'
2.Well Construction Permit#: f./,Aw O@ a��_/� s d far, FROM TO DIAMETER THICKNESS MATERIAL ,
ft ft. in. •'
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.)
ft ft. in.
3.Well Use(check well use):
17.:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural • ❑Mont al/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) tt rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Pour 4i 'i3y,5,f J1
❑Monitoring ❑Recovery ft. It
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation 19.SAND/GRAVEL PACK(If applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO 1 MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. _ ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional shecta If necessary) •
FROM TO DESCRIPTION(color.hardness,soiUroek mac.strain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) it /v ft /�e G�./ /
4.Date Well(s)Completed: 0.....142/1Well ID# 1.-Di/ )
U ft. it. Q�/Q4 { ReJ Sad
35ftt !kikt !d/ove/ Sori/5a.Well Lc ion: .,�
W/ ( / -AVe GGe%e p6//ersecg6eve 10 ft g5'ft a ,"/ 5 1/S�
Facility/OwncrNamc Facility10#(ifapplicable) i/ t t• /ni7ft &frieJe Rol`
Physical Address,Ct .and Zip / //�,( *0 L.' c�4 M r?
_ireie � ,y y(f�' ,i (/- 21.REMARKS JEPP 1 L 2024
County GO Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi anon:
CVdfifQ l 42,71
N W
oa
tore of C ified 445ontractor Dat
6.is(are)the well(s): rmanent or OTemporary
signing tin.form,I hereby cert(' t the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15.4 NC.4C 02C.0100 or 15,4 NCAC'02C.0200 Well Construction Standards and that a copy
If this is a repaut fill out known well construction information and explain the nature of the of this record has been,prorided to the well owner.
repair under=21 remarks section or on the back of this farm. 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-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: p7®.c (it') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing:40 (ft-) information ProcessingUnit,1617 MSC,Raleigh,NC 27699-1617
s
If water level is above casing,use"+•
6 1/1824b.For Injection Wells:Copy''to DWR,Underground Injection Control(iUC)
11.Borehole diameter: (in.) Program,1636 MSC.Raleigh.INC 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
/� Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-1611
13a.Yield(gpm) {T i Method of test: ',
Tabs 1 1/2 Lbs 1
13b.Disinfection type: Chlor. Amount: 1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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