GW1--06606_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.Well Contractor Information: I
Joseph Bailey s • 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
3271-A 3 t // Irf47)/C ve _
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for mold-cased wells)OR LINER(if ap licable). _
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL '
Company Name" uSi ft• `� ft. 6 114 in SDR-21 PVC
pV- ,� any �y•
16.INNER CASING OR TUBING(geothermal closed-loop)'' '
2.Well Construction Permit#: ( p( °jr /6� i FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consauctiorr permits(i.e.U/C,County,State.Variance,etc.) ft. ft. i in.
3.Well Use(check well use): It. tt in. •
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.; -
❑Geothermal(HeatingiCooling Supply) idential Water Supply(single) fL It. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) IS,GROUT
❑irrigation ❑Wel Is%100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 't• 20 rt, Bentonite Pour /I '`✓�Q 8/0
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifcr Recharge ft. fL
q g ❑Groundwater Rcmcdiation
❑Aquifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK(if applicable) .
ty FROM TO MATERIAL. EMPLACF.MENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .20.DRILLING LOG(attach additional sheets ifnecessary).. .- . ' • _
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION[color.hardness.soil/rock Din Frain size.etc.)
0 tt. /G ft.
t e a S erf
4.Date Well(s)Completed: ..i /, Well iD# 0/ g aft. 35 fr, we -ei /
5a.Well Location: ! rt.
r ft
00
phfilr)- kohldee . (1. i-7`' �15' I.® ft (ere .',. 'awl s y. • 6.�
Facility/Owner amc Facility iDk(if applicable) �L /03 ft. ofea/�L,.JI fi dC
al.I I(epiO Rd, n7eopaN�t 'r doll) /�ovft. 90-6� ®'� i e<< R`
Physical Address,/City, d Zip (,fie/,/j�[!� `p\ ft. ft > a f \}
0� m 21.REMARKS i NOV� arty Parcel identification No.(PiN) �V 2 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification: ;-,it,,:+ ,
N Wd ,,, ri.,
_9/42sOL
6.Is(are)the well(s): rmanent or ❑Temporan Sign re of C rtified Well Contrac,r Da
By signing this form.I hereby certify that the well(.$)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15.4 NC,4C 02C.0100 or 15.4 nrC4C 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^21 remarks section or on the hack ofthis form.
23.Site diagram or additional well'details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yoti'may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths if different(example-3@200•and 2(4100') (ft.)
Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR).
If water level is above casing,use"+' information Processing Unit,1617 MSC,,Raleigh,NC 27699-1617
61/18 l"
11.Borehole diameter: (in.) 24b. For Injection Wells:Copy to DWR.Underground Injection Control(iUC)
Program.1636 MSC,Raleigh.NC 27699-1636
Air Rota
12.Well construction method: Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells: to the
(i.e.auger,rotary,cable,direct push,etc.) Copy
county environmental health departmentjof the county where installed
FOR WATER SUPPLY WELLS ONLY: - I 1
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
ethod of test: 1
Tabs
13b.Disinfection type: Chlor. Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018