GW1-2021-01545_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey to J4.�WATERZfnvEs'
FROM TO DESCRIPTION
Well Contractor Name IL /p � ft
3271-A 202ti , 61t. ,� ft ,d -rwt;.%za ° n
NC Well Contractor Certification Number {J Cge�g1C���.� OUTER CASING for mal6 cased tvcll's OR LAMER da"" bte :3
B & K Well Drilling Inc `nn� tQ�` To �lo� FROM TO DIAMETER THICKNESS MATERIAL
0 ft. I q/
ft. 61/4 i" SDR-21 PVC
Company Name X,C.04NER,CASING`OR TQBING euthi ima7 etdsed loo
2.Well Construction Permit#: �1 FROM TO DIAMETER THICKNESS MATE AL
List all applicable well construction permits(i.e.U/C,Cormrv,State, Variance,etc.)
ft. ft. in.
ft. ft. i"•
3.Well Use(check well use):
17:'SCREEN: ,
Water Supply Well: FROM I TO DIAMETER SLOT SEE THICKNESS I MATERIAL
❑Agricultural ❑Munici a blic fL t't. in•
❑Geothermal(Heating/Cooling Supply) EDREsidential Water Supply(single) % ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:aG6ROU7
❑irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite Pour
❑Monitoring ❑Recovery fL fL
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.S AND/GRAVEL''PACK-it:9 'cattle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. FMPI.ACF.MF.NT METHOD
❑Aquifer Test ❑Stotmwater Drainage f__>
ft❑Experimental Technology ❑Subsidence Control fL❑Geothermal(Closed Loop) ❑TracerNG L OG atTO DESCRIP ON(color,hardness,smVrock e, min si etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) Dft ve4.Date Well(s)Completed:� � Well ID# 0ft.16 ft.
5r,.Well Location: Q
a. t�i,\.V�7r,� ft ft.
Facility/OwncrName Facility ID#(if applicable)
ft. ft
fL ft.
Physical Ad css,City,and Alp
`f A Z1 REMARKS
parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N
W ��
Sr t e o Cei i Well Cont etor Da
6.Is(are)the well(s): rmanent or ❑Temporary
v signing this jnnn,/hereht rt'fthat the well(s)was(were)constructed in arcnrdance with
7.Is this a repair to an existing well: ❑Yes or V4___ SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature gfthe of this record has been provided to the well owner.
repair under a21 remarks section or on the hack of this form 23.Site diagram or additional well details:
8.For Geoprbbe/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: (ff') Submit this GW-1 within 30 days of well completion per the following:
Fa multiple rre((s list all depths ijdifferent(example-3(a3 00'and 2@100')
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
/f water level is above casing,use"+"
6 1/18 24b-For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
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 producintt over 100,000 GPD:Copy to DWR,CCPCUA
/ Air Lift Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ® Method of test:
Tabs
13b.Disinfection type: C lor. Amount: 1 1/2 Lbs
Form GW-I North Carolina Department orEnvironmcntal Quality-Division of Water Resources Revised(i-6-201 8