GW1-2021-01542_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey CSI 14.,ATEXIWE>
r�
FROM TO DESCRTMON
Well Contractor Name s ft. ' ✓
r��Air X 9 2021 /C� '�i ft 0/4 /�c� G
3271-A
C/o' r fL
NC Well Contractor Certification Number n Prdc6S9iR9 l$OQTERCASING€oryaal cased 4ceTI' OR EIigER d`a
B & K Well Drilling Inc IrttCrr�3DV��SeCtion FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 4 ft 6 1/4 1n SDR-21 JPVC
Company Name
1b 1N 1ER, OR31 .DIAAETER I eofl ermal,ciased.�oo
2.Well Construction Permit#• �ji N FROMTO THICK�7E55 MATERIAL
List all applicable well construction permit.'6.e.UI ,Comty.State.Variance,etc)
ft ft in.
'/h ft 11
in
3.Well Use(check well use):
T7S.'SCREEN .
Water Supply Well: FROM I TO DIAMETER SLOTSIZE THICKNESS V MATERIAL
❑Agricultural OMunicipal/Public ft ft i"•
❑Geothermal(Heating/Cooling Supply) ential Water Supply(single) f J ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) fS GIi0133
❑Iiri ation ❑Wells>I00,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20 ft Bentonite Pour
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑AquifcrRecharge OGroundwatcrRcmcdiation 19:5AN1)/GI S?EI P�iCK':ifa cable r
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO M1IATFRInt. FM PLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
OExperimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
30:a ILGIN�LOG aUssl adisttenal sheetv3t 2:
FROM TO DESCR ON(color,hardness,soiVroek in size,etc.)
❑Gcothenmal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) fL ft L
4.Date Well(s)Completed: / Well ID# ft ft ��J� J'
ft ft 26 f f i J f", j��< < C'
5a.Well�Locagtion: 9 �y ✓ '
Facility/OwnerNamc Fac�ilitylD#(ifapplicablc) Q ft 0 fL '
ir%/Jr'1* iy!'ur y"/W3�1'r/�7/i�All��. ft ��, ft
" r
ft ft
Physical Aldcss','City,and Zip _
��4 CI �"l A�Cf✓���/ � TL3tEMA'RRS.<'.'. �.� �� _ .ya.,.
� v
County Parccl identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification•
N W 9
Si re o Cef'ified onuactor Date
6.ls(are)the well(s): rmanent or ❑Temporary
B signing this jonn,!herehv certifyth the well(.')xa'(were)cnnstnrcted in accordance n dance with
7.[s this a repair to an existing well: ❑Yes or A NCAC 02C.010(1 or ISA NCAC 02C.0200 Well Construction Standards and that a cog/
ljthis is a repair,full out known well construction information and explain the nature a/'the of this record has been provided to the well owner.
repair under:21 remark'section or on the back ojthis 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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) Submit this GW-I within 30 days of well completion per the following:
For multiple hells list all depths if different(example-3@200'and 2@100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lj nvater level is above casing,use"+"
6 1/18 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (io•) 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 We is producing over 100,000 GPD:Copy to DWR,CCPCUA
d �,v Air Lift Permit Program,1611 MSC,Raleigh,NC 27699 1611
13a.Yield(gpm) t ✓" Method of test
13b.Disinfection type: C IOr. Tabs Amount: 1 1/2 Lbs
Form GW-1
North Carolina Department of Environmcnral Quality-Division of Water Resources Revis%d(i-6-2018