GW1-2021-01537_Well Construction - GW1_20210309

ra_ G. ( a-1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: / ®
Joseph Bailey R ��� 14.wATEWZONES .. `:.
FROM TO DESCRIPTION
WclI Contractor Name p�AR X 9 2021 B y� ft- ft. lw';- r' /7;"'e �'0''e
3271-A Unit / p tf. ft. c J f, �� � ���
NC Well Contractor Certification Number InfOfli� Pr°°SSSIftg Unfit
3tion 15.OUTER CASING for•mull cased well's OR LINER sf a"Iieable ;
B & K Well Drilling Inc DwR S�Ct'0n FROM TO DIAMETER THICKNESS MATERIAL
0 r1. ft. 61/4 SDR-21 PVC
Company Name
J` 16.,INNER CASING'OR.CUBING 'eathermal closedaoo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable well coistuction permits(i.e.UIC,Cotmty,State.Vnrinnce,etr.J
fL fL in.
3.Well Use(check well use): ,
17.'SCRE
Water Supply Well: FROM TO DIAMETER SLOT SIZE ' THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ✓ L ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) _:i&GROUT " y
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&PMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite Pour
❑Monitoring ❑Recovery ft. ft.
Injection Well: fL ft. 77777777777777,.,
❑Aquifer Recharge ❑Groundwater Remcdiation 777777777
19.SAND/GRAVEL PACK-if a` •cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Stormwater Drainage fL fL
❑Aquifer Test -
❑Experimental Technology ❑Subsidence Control R• ft.
❑Geothelmal(Closed Loop) ❑Tracer 2:=DRILLING: OG attiietc:ad(Isdorialsfieets.tfneixss
FROM TO DE.SCRIP N(color,hardness,sotUrock type,gnin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® ft.
4.Date Well(s)Completed: �{
Well ID# .�� �/ ft. e J7 " fL `fit
5a.Well Location fLsy �/ ffL. f.
> Je � ft.
Facility/OwncrNamc Facility ID#(if applicable) V
/
//, /�^ n L ft f
Physica Address,City,and Zip r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one[at/long is sufTicicnQ 22.Certi lion:
N W
Si> t re of ettifie4'rart
Dat
6.Is(are)the well(s): ermanent or ❑Temporary
signing this form,I herehr cedli that the well(s)x•as(were)ennctnrc led in act ordance frith
7.Is this a repair to an existing well: ❑Yes or 1 SA NCAC 02C.0100 or I5A N C 02C.0100 Well Construction Standards and that a copy
If this it a repair,fell out known well constniction information and explain the nature of the
this record has been prorided to the well owner.
repair under;21 remarks section or on the hack 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-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: Submit this GW-1 within 30 days of well completion per the following;:
For multiple wells list all depths ifdilferent(example-3�a)!Z70'and 1@100')
24a. For All Wells: Original form to Division of Water Resource, (DWR),
10.Static water level below top of casing:40 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/(water level is above casing,use"+"
6.1/18 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.) 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 producin>;over 100,000 GPD:Copy to DWR,CCPCUA
/ Air Lift Permit Program,1611 MSC,Raletgh,NC 27699-1611
13a.Yield(gym)_, ( Method of test:
13b.Disinfection type: C r. Tabs Amount: 1 1/2 Lbs
Form GW-I
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 -