GW1-2021-01541_Well Construction - GW1_20210309

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information: OP
Joseph Bailey .q� � ia.'WATERti11 E
FROM TO DESCRIPTION
Well Contractor Name ^oll� ft. 4 ft••
3271-A 1��1�►� (
unit /� `• �s6 f` rd�r �z7ay�
B & 20
NC I W Contractor Certification ell
Well Drilling Namber Sm Inc C l�lt.Oj '�tlO�p�S�n l�'-UUTER CASING fidr mal#3 cased wets OR LINER tf a' cabT
FROM le
TO DIAMETER THICKNESS MATERIAL
DWR 0 ft. 1 ,i'? ft- 61/4 in. SDR-21 IPVC
Company Name B i4 INNERCASING'OR'. [M1NG: "eothern al.closed loo
oC) L/ FROM TO DIAMETER THICKNESS MATERIAL
2-Well Construction Permit#: ft fL in.
List all applicable well construction permit.,4 e. C,Conn{v,State,Variance,etc.)
ft. ft. in•
3.Well Use(check well use):
47..'SCAEEi3 w,
Water Supply Well: FROM I TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
❑Agricultural ❑Mun al/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. I in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft- Bentonite Pour
❑Monitoring ❑Recovery ft. fL
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Rcmcdiation m
19.SAND/GRAVE P,A IC> fa 'cable <
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL FMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control fa fL
❑Geothermal(Closed Loop) ❑Tracer 20.�DRIILTNG'LOG attactiaddtdonalsheets if ``
FROM I TO DESCR TION(co ,hardness,soiVrock rain size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: Well ID# J > ft ft.
fL
5a.Well Location:
s;� SJ D%7/ r✓!J I'�L")l�� /�/` f4 fL
Facility/Owhcr ame Facility iD#(if applicable) /
r ft. fL
UYI Cf' 'V t Q�
�{I -
ft fL
Physical A dress,Ci ,and Zip
21.;REMARIZ5.,,,
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific n•
N W
Signal a of a le Con c 4at4
6.is(are)the well(s): vtrmanent or ❑Temporary
h!),A ning this form,1 herebv certi that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and'hot a copy
if this it a repair,fill out known well construction information and explain the nature of the of this record has been provided to the xel!owner.
repair under:21 remarks section or on the hack of thin 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple veils list all depths if dierent(example-3@ 0 and 2@!00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:40 ft) infortlation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above c•asiag,use"+"
6.1/18 24b.For injection Wells:Copy to DWR,Underground Injection Control(iUC)
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,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: a
13b.Disinfection type: or. Tabs Amount: 1 1/2 LbS
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018