GW1-2021-00501_Well Construction - GW1_20210210

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14::WATEIt'Lt3N
FROM TO DEscRrPTIO
Well Contractor Name
ft 157 fl- G1,G• �p
3271-A tit ft-
NC Well ContractorCertification Number IS-.U[7I>iR:CA$1NG(#or t5raiiaased wells ORI IiRR
B & K Well Drilling Inc FROM TO DIAMETER+ THICKNESS MATERIAL
0 ft.
Company Name ft 61/4 SDR-21 PVC
� 011/
j r i4.T:NNER C l IA0 OTf:T13$fi Yl eiymsl dasrtldoo '
2.Well Construction Permit#• FROM To DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits f.e.UIC,Country,State.Variance,etc.) It.
ft .in
3.Well Use(check well use): #0
ft ft in.
Water Supply Well:
17'St itEEN
PFY FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
OAgricultural OMunicipal/Public fL ft. in.
DGeothermal(Heating/Cooling Supply) enttal Water Supply(single) Aft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(Shared) 18iGRt3UT
❑Irri ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fl• 20 fL Bentonite Pour
OMonitoring ❑Recovery ft fL
Injection Well:
fL fL
❑Aquifer Recharge OGroundwater Remediation
19:5AN1)/GItAyEG'PACK,ffa c6lfle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test DStormwater Drainage ft fL
OExperimental Technology ❑Subsidence Control ft fL
OGeothermal(Closed Loop) ❑TracerO DRI1 t1PIGtii sum =addST `'3iiect+ff:u'`
❑Gcathcnnal(HcatinglCaolingReturn) D Other(explain under
�#2 FROM TO DESCRIPONcolor,hardness,soiltnmk in eft.)
Remarks) ft
4.Date Well(s)Completed: Well ID# l __ ft. IL
Sa.Well Location: fL �" ft ti•f dr✓
Facility/Ow4rNamc
� Facility ID##(if
-p�pi_icaj lc)) A01 ft ft
/W.ei © ft ft f
Physical Address,City,and Zip ft ft
ounty Pascal Identification No.(PTN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one W/long is sufficient) 22.Certific 'on:
N wr
6.is(are)the weil(s): rmanent or ❑Temporary St ure ofC ified en Cunt/ Date
signing this.form.I herebv certify that the well(s)xms(were)constructed in accord6nre with
7.Is this a repair to an existing well: Oyes or 15 4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cmistruction Standards and that a copy
if this is a repair.fill out known well construction information and evploin the nature of the of this record has been provided to the melt owner.
repair under-2/remarks secrion or on the back of this form,
23-Site diagram or additional well details:
S.For Geoprobe/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-1 is needed. Indicate TOTAL NUMBER of wells
(add'See-Over'in Remarks Box).You may also attach additional pages if necessary.
a
drilled: 14.'SU$11'iiTTAL INSTRUCTIONS
9.Total well depth below land surface: �,, 'e• (ft-)
For multiple wells list all depths ifdif)erent(example-3(a3200`and 2 0100') (�S�this GW-1 within 30 days of well completion per the following:
41) `24a. For All•.Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) infomration irocessing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
If rcater level is above casing.use
6 1/1$ r `' ' "24btF)3r injection Wells:Copy to DWR,Underground injection Control(RUC)
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 environmenta,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
I3a.Yield(-.pm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: r' TabS Amount: 1 112 LbS
Rcv sc i 6 fi-241 R
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources