GW1-2021-05718_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey PEC N E 14.WATER ZONES
FROM TO DESCRIPTION '
Well Contractor Name
3271-A JUL 0 6 �021 ft. ft.
NC Well Contractor Certification Number g Unit
Inf�rrnratlon processln 15.OUTER CASING for multi casediwells OR LINER it a 1icable
B & K Well Drilling Inc �o rR Seciion FROM To DIAMETER THICKNESS M.ATERIAI.
0 ft. w a. 61/4 1n SDR-21 PVC
Company Name t I,n 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:_ 3)(,+�s 4 FROM 'ro1 DIAMETER I THICKNESS MATERIAL.
List all applicable++'ell rnnsd'u<vinn permits(i.e.UIC.Cnto+tr.State.1'orianre,etr.l ft. ft. in.
3.Well Use(check well use): 112.ft. ft. in.
] .SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Muntc ]!Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) t. fL in.
❑h[dustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20 ft• Bentonite Pour
❑Monitoring ORecovery
injection Well: ft ft.
❑Aquifer Recharge OGroundwater Ra»cdialion
19.SAND/GRAVEL PACK if a livable
OAquifer Storage and Recovery ❑Salinity Banner FROM TO M.%TF.RIAI. F.MPI.ACF.MEN'T METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft, ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIP ION(color,hardness,soil/mck e, rain size,etc.)
❑Gcothcnnal(FicatingiCooling Return) OOthcr(explain under#21 Remarks) ff. ft,
`� 1,6 Ias1
4.Date Well(s)Completed: Well ID# / 4 ar
it. ��Qrt/ ��`t A�
ft. a 1WR.
5a.Well Location:
IUeST �,�L peek ft. ft. ✓ �-.,e
Facility/OwncrNamc Facility M4(ifapplicable) ft.
ft. ft.
Physical Address,C'ty,and Zip ✓
��n Gw /r 0/1,/1�`� 27.REMARKS
County -r (� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lao'long is sufficient) 22.Certification•
N W "Agr
/
6.ls(are)the well(s): ermanent or .❑Temporary Si, a[ure Certified Vltell Con actor Date
signiuF d+i.c loco+.I here e+vifv that the well(s)N•a.c(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 010- /5.A.\'C.4C n2C.oleo or 15.4 YCAC 02C.0201)If'ell Cnnctr7netin,,Sfondardc and that n rain,
/f this is a repair.fill out knrim,well rnnstrurtion information and explain the nature of the nJ this re,a,d has bee,,prm ided to the ter/t onner.
relxur+ender=Jl remorkc sertion or on the hack at'thi.c form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sarne You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
Farm+hiptc trells list all depths ifdi(ferent(erarnple-3(da_'00'and 2(dt100')
40 24a, For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: (ft.) Information Processing Unit.1617 MSC.Raleigh,NC 27699-1617
if haler lei-el is ahm'e cusing,use"+"
1 I.Borehole diameter 6 /18 (in.) 24h.For Injection Wells:Copy to DWR.Underground injection Control(iUC)
Program. 1636 MSC.Raleigh.NC 24699-1636
12.Well construction method: Air Rotary
24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
(i.c.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 27699-1 61 1
13b.Disinfection type: hlOr. Tabs Amount: 1 1/2 Lbs
Revised G-6-'_01 R
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources,
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