GW1-2021-00465_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14kWATER ZONES
IRON TO I DESCRIPTION
W ell Contractor Name ,s
vR. �. ft. F 4 /
3271-A
NC Well Conti actor Certification Number 15. UTER CASING fur mPlH eased wells OR LINER(ifa bk
B & K Well Drilling Inc P16.
M TO DIAMETER THICKNESS MATERIAL
tt. 'tL 61/4 in SDR-21 PVC
Company Name 1NNER CASING OR TUBING eachermal closed-lao2.Well Construction Permit�: � (ATA/ JW rr' M TO DIAMETER THICKNESS MATERIAL
Li¢all applicable well conrnr.rrimr permits(i e.L7C Counn,Smra Vmmura,em.) ft. fG in.
/LH ft in.
3.Well Use(check well use): 7
1ZSCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mun al/Public R H. In
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) 1&GROUT
❑Irri alion ❑Wells>100.000 GPD nfE
MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: f- Bentonite Pour
❑Monitoring ❑Recovery D.
Injection WeII: n.
❑Aquifer Recharge ❑Groundwater Remediition 19.SAND/GRAVEL PACK Ka 'nble
[]Aquifer Storage and Recovery ❑Salinity Barter FRUAt ro 'd ATERIA I. FMPI.ACFy1FNT nIFTHOD
❑Aquifer Test ❑Stnrmwater Drainage
']Experimental I echnology ❑Subsidence Control A14
❑Geothertnal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional stani It necea
FROM TO DESCRIPTION I ak, ardnesi,,fl/oak gpe, tou,etc)
❑Gcothermal(Hcating/Cooling Return) ❑Other(explain under N21 Remarks) fL ft
i f i
.O T
4.Date Wells)Completed: �?I WeII ID ft. ft'# �d��y - 9P✓/�
c
5a.Well Location:
ft.
/+IrRC( nGe rj Vend�w I/U , /� '/ Vr t er { n.
Faullry/Owner Name Facility IDk pf applicable / ✓ r
f
7�ur� t.
Physical Address,City.and Zia
� T,t✓�a �o /iGo6ori�Da�oSf 1.REMARKS
Coauntyunty Parcel Idcmificomn NO.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lit well field,one[at/long is sufficient) 22.Cerfi ea on:
N
Si wre of rifled I onuacmr Date
6.Is(are)the well(s): anent or OTemporan
- r g 4 rh'.f II h'- r that rh Ill 1 s(v I 'n.r yeti o d ae with
7.Is this a repair to an existing well: ❑Yes or li 4 \CAC o2C hoar 15A'CAC,12C 11 no Ne0 C nvcrion Standards and char a cope
l/chi.is a e/a)-.III tiro Annxn.ell ronm mrto I rna+inrr a rd erp! nr+lr, tar re a/die 1 + emrd Ira.Aeen pro ided a the xr/1 n.mre..
repair under-21 rei recomr or on the back of+dfe f,rnr l i 01 ZU(� 23.Site diagram or additionW ,tell details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of thiFp£ge to provide additional Well construction info
construction,only I 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: (ft.) Submit this GW-I within 30 days of well completion per the following:
For mo/nple wells lry all Aeptlr,ifdllerem levunple-3(a2.tin and-' 00r) ..
24a. For All Wells: Original fomr to Division of Water Rcsourccs (DWR).
10.Static water level below top of casing: 40 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If.,m,,level it ob,v,,,,m, use"+"
S1/1$ 24b. For Infection Wells:Copy to DWR,Underground Injection Control QUQ
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: Air Rotary 24c.For Wit[ S ppl d Op -Lo P Geothermal Rutre n Wells:Copy to the
li-a auger,rotary,cable,direct push.etc.) county environmental health department of the county where installed
[13a.
WATER SUPPLY WELLS ONLY: 24d.F Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
ield(gpm) Method of test:Air LiftPermit Program,1611 MSC,Raleigh.NC 27699-161Iisinfection type: C r. Tabs Amount: 1 1/2 Lbs
A
Form 6 W-I sort Carolina Departmont of Env l ronmental Quahry-Division of Water Rcsourccs Rersed fi-(.COI A