GW1-2021-05716_Well Construction - GW1_20210706

G a9
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey 14.WATER ZONES f
Litovl / uEscTt�/ v (/
Well Contractor NameREU ft. f[.
3271-A 1410 fL . � ft �
NC'Well Contractor Certification Number JUL 0 " 2021 .
15.OUTER CASING for multi-cased wells OR LINER if a ticable
B & K Well DrillingInc 1 ♦nr Processin Unit FROM D1.4METER THICKNESS M11._ ATERIAL
TI} __ - g O ft. tt. 6 1/4 SDR-21 PVC
Company Name �(`�S�CIIOnI
�9�°�/33 y� 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM ro DIAMETER THICKNESS MATERIAL.
Liss all applicnhle well ro++.smwlinn pernrir.s(i.e.UIC.Cnunnv.State. I bribed.etc i^-
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSI7.F THICKNESS MATERIAL
❑Agricultural ❑Municipal.%Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) I cntial Water Supply(single) tq• fL in.
01ndustrial,Conimercial CResidcntial Water Supply(shared) g•GROUT
❑lrrl atlon E%Vells>100.000GPf) FROM TO MATERIAL EMPLACEMF,\T METHOD d AMOUNT
Non-Water Supply Well: O a. I 20 ft- Bentonite Pour
❑Monitoring ❑Recovery ft. ft-
Injection Well: ft. ft. I
❑Aquifer Rcchar,c GGroundw'ater Rcmcdiation 19.SAND/GRAVEL PACK if a ticable
❑Aquifer Storage and Recovery ❑Salnu[y Batl-ier FRUM TU s1.�TF.RI Al. F'.MPLACEMF.ST MF.TIIUD
❑Aquifer Test ❑Siormwater Drainage tt, ft.
❑Experimental Technology ❑Subsidence Control
i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color hardness.soiVrock type.grain size.etc.)
❑Geothermal(HcatingiCooling Return) ❑Other(explain under 421 Rcmaiks) ft ft.
0 6
4.Date Well(s)Completed: o?� Well ID# pf� ffafL tc 44O
tt. ft. t,r1id nar/7 Saj r
5a.Well Aldocation.
n . rd Get v ft. ft. /}-/� ♦mot
Facility t(ifapplicable) 07�
Fatiliry%Ourocr Name f/
,231 1?t-lyeL
ft. ft.
Phvsical Address, y.and Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
f utll lield,one Iatilong k sutlicicm) 221.Certific• ion:
N NN
r orbI
Sig a re of a tied omractor Da
6.Is(are)the wellW: anent or ❑Temporan'
8 irrr rlds torn+,1 herehr ce,-'(&th t +e u11&r uns(K'c eel rnnurucled in accardauce vrah
7.Is this a repair to an existing well: ❑Yes- or ..a.\'C'.4C u2C.ulnn nr Ii.J A'C.4C n ..n_no n'!!C'n,+.anrcrinn St n,durds mrd that n cope
n/rhn,-, d lion bee„1,n,lded in the hell
if this is a repair.fill nut knnHr+yell consuvclion m/6r,nminn and e.rplain d+e nahae,q the
nw'nrr.
rrptnr under '21 re+nnrkr serdnn or nn the hack of this/nrm. 23.Site diagram or additional well details:
3.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-I is needed. Indicate TOTAL NUMBER of wells (add'Scc Over'in Remarks Box).You may also attach additional pages if necessay.
drilled: y 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 (ft') Submit this GW'-1 within 30 days of well completion per the following:
Fw multip/c•+cells list all deaths it dijlerent(aye iple• &720n _0:100')
24a. For All Wells: Original ftiml to Division of Water Resources (DWR),
10.Static water level below'top of casing:40 (ft.) Infonr ation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11,ruler level is uhure•casing.use"+'*
6 1/18 24h. For Injection Wells:Copy to DWR.Underground Injection Control (TUC)
11.Borehole diameter. (In.) Program.1636 MSC,Raleigh.NC,i27699-1636
Air Rotary
12.Well construction method: 24c.For Water Supply and Opeti-Loop Geothermal Return 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
h't
Air Lift Permit Program.1611 MSC.Raleigh•NC 27699-101 1
13a.Yield(rpm) ethod of test:
Tr Tabs 1 1/2 Lbs li
13b.Disinfection type: itmount:
Fonn(M-I North Carolina Department of En%nonmcnial Quality-Di%'i:aon of\\ater Rcsources Revised 6-6•20I8
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