GW1-2021-00466_Well Construction - GW1_20210210

Q ai ao a
WELL CONSTRUCTION RECORD (GV1'-1) For Internal Use Only
1.Well Contractor Information:
Joseph Bailey FLI WATER ZONES
FROM TO DESCRIPTION
N'dl Can[2cmr Nanlc � ft.
3271 A ZSD. y/G«. ! f/ccla /
NC Well Cerfoamor Cenincm,en Srmber 15.OUTER CASING forlined sed wells OR L[NEA oa liohl¢
ROM 10 DIAMETER
B & K Well Drilling Inc NICKNE55 MATERIAL
p In ft. 161/4 SDR-21 IPVC
40
Company Name 16.1NSER CASING OR I"U'RLNG emheratel closed-loo
wPil FROfI O OLUIETER HICKIESS
-�a-aoaa -iyay�y MaI ERHI
2.Well Construction Permit#:
l yr m apphvah/e well n.nn.�. n""n"e(i e UIC.C11 State. l'artmu e.era.)
fl. ff 1
3,Well Use(check well use):
7.SCREEN
Water Supply Well: FROM TO DIAMETER SCOT SIZE THICKNESS MATERIAI.
]Agriculluml ❑M Icipal:Public n. n. Io-
-lGeotcamsel(HeaongCwlingSupply) esdenHal Water Supply(single) D, ly, 1
C Ltdu'uiallcmuoercial ❑Residential Water Supply(shared) .GROUT �—
Clm atlon ❑WelIS> I00.000 GPD FROM TO MATERIAL EM PLACE>IENT>1ETHOD&AMOUNT
Son-Water Supply"'ell: 0 ° ' 20 !B1Bentonite Pour
C\lonitoring ❑Rcamery ft. ❑. -
Injection Well: �- R, R
Aquifer Rech2rgc ❑Groundwater RcnlediaGon 19.SANDIGRAVEL PACK if applioable)
:Aquifer Stmace and RcColeR ❑Salinoy Banier FROM TO MATERIfI_ FMPITCFVFNT fIETHOD
_Aquifer"lest ❑Stormrcater Drainage ft. I ft.
❑Experimental'fechnologg ❑Subsidence Control n. f.
—Geothermal(Closed Loop) OTracer 0.DRILLING LOG pooch additional once.if neeessary
FROM TO DESCRIP ION(color,hardness.wit see A 1,,,.train size,es.)
=GcethermaI(I lead If Cool ne Rem ml Conner (explain under#21 Remarks) ft to
4.Dale Wells)Completed: t- 13— l Well ID# ��r Y Q ft. ft.
R. (t.
5a,Well Location:
(r �� — ft. 4 n r c
Facdr,MD Ii annluu ble)
ft. R.
F t l t,�uTe v e i
3& �S—T n'IllS i /I16 RZ To
_I
PFas cal Add-,,,,,City.anJ Zip ft. ft.
Corn, Parcel ld,ef ficaoon N'o-(PIN) - ----
56.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
n wdl field,one Is,long"suing,eml 22.Certification:
N _W �V
ti1S i v C t a or D
b Is(are)the well(,): rmanenl or OTemporarw
��� B c err (non,lie h Ih,rlmt 4,)" _t I - I ed ."Mn"'sn'
Is this a repair to an eAlsOng well GYes or 'yNo ;, C B C.U/UO bA SCJC 1 C o On If 11 C rre'Icnor Sro A i 1 1.t n rnpr
r� deal hl I ds"Ilh Il n. r:
tide", -'c" Id nvl Ors"" rell.n r lrrion-vlor a a';d, h m�r "
rrpo r under I unm-kr eec,. ,n'o, the n,,k rf,hi, 23_Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells ha.inu the same You rare use the back of this page to provide additional well construction into
construction,only I CiV, I is needed- Indicate TOTAL NUMBER ofrvclls (add'See Over'in Remarks Rox).You may also attach additional pages: necessary.
drilled. _ 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 41� (ft') Submit this GW-1 within 30 days of well completion per the following:
Fo .nu01p1e ll I l a d 11 .. pl J'.'00'oed"I100')
_ 24a. For All Wells: Original toms to Division of Water Resoulcea LOAR).
to.Static water level below top of casing: a0 (f I Information Frocrss'mg knit-1617 MSC Raleigh,NC'-7699-1617
I vrerlmc.l -n ang. e•e -
- 6 1/18 246. For Injection Wells: Cops to D1VR, Underground (njecuon Ccntrol (IUC)
1 I Borehole diameter: (in.) Proeram. 1636 MSC Raleigh.INC]7699-1636
12.Well construction method:
Air Rotary 24c.F Wafter S ppld Op p
-I Geothermal Return Wells: Copl'tothe
uc.roger.rotary.coblc.dnca push.etc.) county cncironmental health department Of the count)where ms[alled
FOR WATER SUPPLY\YELLS ONLY: 24d. F Water Wells p rooming over 100,000 GPD: Cope 10 DV, CCPCUA
13a.Yield(gpm) Method of test:
Air Lift � Permit Proerem,l611 MSC Relelgh.NC.7699-1611
136.Disinfection type: Cr. Tabs_. Amount 1 112 Lbs
Form Gl4'-I
VonhCar.Loa Deparuncnl al Enanrunenri Qualrrp Dlci,non of Wn¢r Ro om cc. Rat.ed6-6-2oIF