GW1-2021-01083_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey 14.WATERZONES
FROM TO DESCRW x
weh ro Comrecr Name a D. a
3271-A 9 " G fL Sin•U r4 C VIC 2Me
NC Well Contractor Certification Number IS.OUTERCASING for Aal4-rase4w OA I.iNER sfa A
B & K Well Drilling Inc FROM TO DIAMETEK lean-w .CS MATERIAL
p ft. ��oZ a 6 114 m SDR-21 IPVC
Company Name ,/ I&INNER CASING OR'TBBINsa --
N� FROM TO DIAMETER THICKNESS MATERIAL
con
2,Well Construction Permit#: R ft. in.
Lin all avvlicnb/e..ri/omunvrrimi permitt li.e.L'fC.Cmmrv.Srore.✓nrmnce,rmJ t
it. a
3.Well Use(check well use): 17,SCREEN n.
Wal r Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
gricultural Municipal/Public It. f ft.. in.
❑G/eothenmal(Heating/Cooling Supply) MResidential Water Supply(single) fL h s. i
Rtndus[rial/eommacial ❑Residential Water Supply(shared) I&GROUT -`-
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD dv ANOUNT
❑Imi anon p IL 20 it. Bentonite Pour
Non-Water Supply Well:
❑Monitoring ❑Recovery fL IL
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Rcincdianon 19.g,Wp/GRAVEI,PAfK
MATEp1Al. EMPIACF.MENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier mom fL TO It.
OAquifer Test ❑Stormwater Drainage
R
❑Experimental Technology ❑Subsidence Control _
OGeothermal(Closed Loop) ❑Tracer 2o:DRQ.1�'1GIAG(ati adbGevalabxrotr
FROM TO D TION(sabr,hareeess,rwpr^ta a,,es.)OGwthermal(Hcaling Cooling Rcmm) ❑Odtcr(cxplainundcr#21 Remarks) O fc fL /
4.Date Well(s)Completed: //9 err WeII ID# 0 IL rL kIn
IL
on:5a.Well Sh. rL ,�ni5 �Oa/
< i ,)ft. +t. n
Facility/Owner Namc FamlirylDs(fapp1mablc) (/
le77e d,, fL f
IL ft
Physical Ad s, ry.and Zip
/fin
County Parcel ldcmifieaum No.(PTN) f
5b.Latitude and longitude in degrees/minutesbcconds or decimal degrees:
gtj . eon ( mvT� o d e TIi �
(if well field,one la✓long is suf ici at) 22.Certification:
N W
stare of C i and all
Contra mr Dam
6.Is(are)[he well(s): ,moment or OTemporary
p eiR^mg,his/orm./hereks 716 rhar the ur/l/d u'as(were)consrnrned in aorordmn-e wish
/' 15.1 h'CAC 02C 0100 ar 15A NCAC 02C 0200 Weil Cmrrnvcnaa Standards and rhar a cop,
Jf Is this irepair to an neat wellting
❑Yes m d njrnis.e,rd/ms bee^prm',ded..the w,11 awtmr.
/jnc�r is a repair,fill our bin.+�well rommrorinn information and esplain the nave of de
repmr under=21 remark,section or on the back of tbir form 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe(DPT or Closed-Loop Geothermal Wells he s ^ cid'Sce Ovd in Remarks Box).You may also attach additional pages if necessary.
conm stctioq only I GW-1 is needed. Indicate TOTAL NUMB ells /
c.s� 4.SUBMITTAL INSTRUCTIONS
drilled.
9.Total well depth below land surface: (it') Submit this GW-1 within 30 days of well completion per the following:
Far mrdriple wells to,all depdrs rjdp rem(r=amvle-3@20n and 2910a)
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
10,Static water level below top of casing: (TO Information Processing Unit,1617 MSC,Raleigh,NC 2 7699-161 7
f/wmer level it aburc rasing.use
6 1/18 24b. For Injection Wells:Copy to DWR,Underground Injection Control (TUC)
11.Borehole diameter (m-) Program, 1636 MSC,Raleigh.NC 27699-1636
(i Well construction method:
a
Air Rotary 24c.Forwater Supply d Op -Loop G othermal Return Wells:Copy to the
1 i.e.auger,rotary,cable,direct push,etc ty.) coun environmental health department of the county whore installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells pod a over 100 000 Grp:Copy to DWR,CCPCUA
13a.Yield(fpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:
or. Tabs Amount: 1 112 Lbs
Rcvisnib6-2018
Fona GW-1 None Carolina Dcpanment of Environmcnml Quality-Division ofwarcr Rreourcc