GW1--06609_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name •
3271-A / Aft. f-a'f`-II[[[[C7_SinflI( / oervrG.ztie
NC Well Contractor Certification Number 3 _/J 3% t- tlltt 4 ) T limbic)
15.OUTER CASING(for in -cas wens OR R(if ap Ic)
B & K Well Drilling inc FROM /TO I DIAMETER THICKNESS MATERIAL
Company Name 0 ft' /OC ft* 16 1/4 I, in• SDR-21 PVC
• • R cAq J II / V# 16. M�tER CASING vOR TIDINM(geothermal closed-loop)
2.Well Construction Permit#• t/(p FROM TO U DIAMETER THICKNESS MATERIAL
List all applicable well consavetiOn permits(i.e.U1C.County.State.Variance.etc.) ft. ft. ( in.
3.Well Use(check well use): fL ft. j in.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Munici lie fL ft. in-
❑Geothermal(Heating/Cooling Supply) rdential Water Supply(single) fL rt. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells%100,000 GPD FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft Bentonite Pour
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcincdiation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fc ft.
❑Experimental Technology OSubsidence Control ft. ft. '
❑Geothermal(Closed Loop) ❑Tracer .20.DRILLING LOG(attach additional sheets if necessary).. '
FROM TO I DESCRIP ON(color,hardness sail/rack type.grain size.etc.)
❑Geothermal(Hcating/Cooling Rctum) ❑Other(explain under#21 Remarks) C J
e fL 1 S ft I �t ,�+ 0/
4.Date Well(s)Completed:h/31/ a t/ Well ID# -1 f�� f� 3 I (wI/,IO!/
5a.Well Location: /// eft. / 5fL ��6t . t4�/
/," h fr e Il�bol l4Z4 l7 ` 5-ft.
" {P 6•�'r,4i 1 S i!
6..4l n r9 7s i eft. )kift
t. ej Hie ``
Facili /OwncrNamc Facility11)6(ifapplicable) J Q !Y(
.ati/ 64-lRij 1k`.S` soile V6dg4ti) 1 Q 0 ft. SbfL ' r..
Physical Ad css,City,and Zip J ft. ft Y�t�.. _ i." .,.(1".-'t `�)ii..• ;)
tL 6 �))�/ -aV oil, 21.REMARKS , AI -. •
County Parcel Identification No.(PIN) I. NOV '1 2024
5b.Latitude and longitude in degrees/minutes/seconds.or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification: [;;.;;,?�_:•3
6.Is(are)the well(s): ermanent or OTemporary _ azure fCe i Well Con t Date
i By signing this/•Orin.I hereby err that the n•all(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11,1c 15.4,NC4C 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=2l remarks section or on the hack of this form. i'
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:erene I �c (ff") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3`,-00•and 201 or)
i
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
11.Borehole diameter:6 1/18 (in.) 24b.For Injection Wells:Copy to DWR.Underground Injection Control(IUC)
Program.1636 MSC.Raleigh.NC127699-1636
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
I'
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 3*iMethod of test:
Air Lift Permit Program,1611 MSC,Raleigh;NC 27699-1611
, _ _
136.Disinfection type: Chior. Tabs . Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6--20IS