GW1-2021-01538_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information: '` , ®
Joseph Bailey y
FROM TO DESCRIPTION*
Well Contractor Name fL fL T y
Pf1 AK
3271-A ft. fL
Un' _
NC Well Contractor Certification Number prOC2SS1n� ;,15:.OUTER CASIRG #ot mel(i asedsivi il" 'OR;LINER tfa""Tcab
Ir,fiarm�t��n FROM TO DIAMETER THICKNESS MATERIAL
B & K Well Drilling Inc DWR Se l0n 0 ft. 'ft. 6 1/4 SDR-21 PVC
Company Name
pJ 7 :tIS;i1Vi�,lERCASTPIG:ORTIJBING1 eo't}iermal.cliisedaoo
.J FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �� fL fL in.
Lisr all applicable well consuvc•tion permits(i.e.UIC,County.State.Variance.etc.)
ft ft. in.
3.Well Use(check well use): r - v
7lSC ENR$ ;..
s
Water Supply Well: FxoM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici al/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esrdential Water Supply(single) 1 L ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑lrri ation OWelis>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite Pour
❑Monitoring ❑Recovery ft. fL
injection Well: tL fL
❑Aquifer Recharge ❑Groundwater Rcmcdiation
]9:SAND/C,R+,t.�!E7 PACK .a
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Stormwater Drainage
❑Aquifer Test tL M
❑Experimental Technology OSubsidence Control / ft fL
2 '.BRILLiL�ItiOGatfa ia
OGeothennal(Closed Loop) ❑Tracer FROM DFUSC bTIsOhNe eebl5ofr.uheacrrdne ss,sorlro ck
tyl3e,itimin size,etc.)
OGcothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: /� Well ID# O/ `�la- ft. �.fL 4V�
ft. ft oL' ��f�ti�I/ j rld,l
5a.Well Location:
T l ft. ft.
ft. j fL
Facility/OwncrNamc Facility 1D#(ifsPplicable)
CJ —. yf �y �,p /1 / ft. fL
ft ft.
Physical Andress,.City, d Zip
ilk q�I '21,:REMARKS,:.:-:.
County
Parcel Tdcndfrcation No.(PiN))))
51b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CertMica'on:
N W
Si a of Certi ed Wel ontmct r Date
6.Is(are)the well(s): Vermanent or ❑Temporary
By fining this form.1 herehv certify t the uell(,r)was(were)constructed in ac•c•ordance with
7.Is this a repair to an existing well: OYes or o 1 NCAC 02C.0100 or/SA NCAC 02C.0200 well Construction Standards and that a copy
If this it a repair,fill out knoxot well constnicrion information and explain the nature of the of this record has been provided to the well owner.
repair under i:21 remarks section or on the hack of this form. 23.Site diagram or additional well details
You may use the back of this page to provide additional well construction info
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if recessary.
construction,only i GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: IQ / (ft-) Submit this GW-1 within 30 days of well completion per the followiig:
Far multiple%•ells list all depths ifdierent(example-3@200'and 2(a3100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 (ft.) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
24b.For in
6'1/18 jection 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 prod__ over t00,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) % ,f Method of test:
Air Lift Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Ch or. Tabs Amount: 1 1/2 Lbs
Revised 6-6-201 R
Form GW-I
North Carolina Department of Environmental Quality-Division of Water Resources