GW1-2021-00494_Well Construction - GW1_20210210

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WELL CONSTRUCTION RECORD(GW-1) For Intema)Use Only:
i.Well Contractor Information:
Joseph Bailey
Y 14.Wri7`ER`Zt)1s1ES' r ..
FROM TO DESCRIPTION
Welryryi Contractor Name 3L7 I�t1 fL 06 IL /��I CaGr#f -, 4mil ft
NC Well Contractor Certification Number lbs. ft r✓!F?$G w=
1'S.:OUTER CASINIG #onto ail3 csifed we3!' OI2 T iNER If:a""i cable
B & K Well Drilling Inc FROM TO DIAMETER: THICKNESS I MATERIAL
ft. t ft. 61/4 'in- SDR-21 PVC
Company Name 'n
libINNER. G:OR=�kSI�TG ef+'thermal:dosed-lao ;:'
2.Well Construction Permit/$ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits Ox. CC,Counrv,State.Variance.etc.) ft ft in.
3.Well Use(check well use): A14 fL ft I in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agr1CUliLLral ❑Munlet al/PubliC IL ft In.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑Industrial/Commercial DResidential Water Supply(shared) I$GRflVT
L
❑irri ation OWells>100,000GPD FROM TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0 fl• 20 R' Beltonite POUF
DMonitoring ORecovery ft fL
Injection Well:
ft ft.
❑Aquifer Recharge OGroundwater Rcinediation
19.SAl!TD/6itAVEX''PACK if a collie
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL: EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft ft
OExperimental Technology OSubsidence Control Ad
ft ft
OGeothermai(Closed Loop) CTracer O.I1R '*m? 'L06!attsr:attdittemalisheetsif "'"
OGeothcnnal(Heating Cooling Return) OOthcr(explain under#21 Remarks) FROM To D oN cobr,kartiness sotvrocR a to size etc.3
{ j IL
IL
4.Date Well(s)Completed: �`� t Well ID# �� fL f IL 4/ �(jd
Sa..Well Location:
/0��2 �Pa/G�G�iIGI�� irI lJkl /S� ft. ft !�
Facili /O�wjnerNam/e/ f/��fp j/�,A Facility ItJ)//#(if applicable) ft. !_i� fL �p C t,�a0- d,
1♦f 1 ' ♦yinq&(kJ,,l-�=— fL i�Y1 ft tj
Physical Address,City,and Zip ft. ft
21/5 6053 > IR
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certifica on• /
N W
6.1s(are)the wel)(s): ermanent or OTernporary ;,�A
tore of ni ell Con tVial
Date
signing this form.I herebv sehe noel((.)was{were)rnnstnrcted in anent mice with
7.Is this a repair to an existing well: Dyes or ti„ _✓� G NCAC 02C.0)Ofl or lSA NCAC 01C!0200 Well Construction Standards and that a cony
ff this is a repair,fill out known well consiniction information a)nd Psplain the natu o}�� l of this record has been provided to the well owner-
repair under.21 remarks section or on the back of I&T form r. 1• 'i 1
C G� 4''33Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having thesar�ie`'; -Vou may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NMBE)t,`of ivglis?,: ,�11 (add'See Ovet in Remarks Box).You may also attach additional pages if recessary.
U
drilled. A'n V t '• ''1
t J' 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 sells list all deptlrs ifdifferent(example-3{a OO*and 2@100') _
10.Static water level below top Of casing:40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ffl voter level is above casing,use
Information Processing Unit,1617 MSC,Raleigh,NC 2 7699-1 6 1 7
"+"
6 1/18 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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 Retain 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 producing over 100,000 GPD:Copy to DWR,CCPCUA
.13a.Yield(gpm) Method of test:
Air Lift Pen-nit Program,1611 MSC,Raleigh,,NC 27699-1611
13b.Disinfection type: h or. Tubs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality•Division of Water Resources Revised 6-6-201R