GW1-2021-05713_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey �� add 14.WATER ZONES
Well('ono actor Namc E k FROM TO DESCRIPTION
3271-A JUL 0 � 2021 /1d rt. /� ft.
r�ut,� yy ft. 71fIr I �T
NC Well Contractor Certification Number �IOG@S$1C)(,�
t �t1011 15.OUTER CASING(for mu ti-ce wells)OR LINER tf a licable
B & K Well Drilling Inc frlfc[tT �`ntt`J�CY+ FKOM IO UL4ME9'EK THICKNESS MATERIAL
0 Q ft- 6 1/4 in• SDR-21 PVC
Company Namc ^ I /
70 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM 1 l'O 1 DIAMETER THICKNESS M.4TERL4 L.
List all aPplicnhle erel/<au'trurtion per nut.,0-U1C.Cnt n•.Sint,. I orimtce.etc) ft. ft. in.
3.Well Use(check well use): /VA
ft. I ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural CMum al/Public It. ft. in.
OGeothermal(Hcating,Cooling Supply) esidential Water Supply(single) t• ft. in.
Dhtdustrial•Conimercial ❑Residential Water Supply(shared) 18.GROUT
O Irri ation DNVells> I(0A0 GPD FROM I TO NUTERI.AL EMPLACEMENT METHOD&.ANIOUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite Pour
ONlonitoring DRecor'ery f, ft.
Injection Well: ft. ft.
OAquifer Recharge OGroundw•ater Rcmcdiation
19.SAND/GRAVEL PACK if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO pLATF.RIAI. F.MPLACF?IFNT METHOD
OAquifcr Test` ❑Stomlw'ater Drainage R, ft.
❑Experimental Technology ❑Subsidence Control H. ft.
DGeothennal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO DESCRIPTION-(color,hardness,sotUrock type.grain size,etc.)
OGcotlicnnal(HeatingiCooting/RetumQ)� )Other(explain aun�de!r�2I�Rcl�marks) ft. ft,
14IRJ�LL �f�i2�L_- O!
4•Date Well(s)Completed: Well IDtt O tL ft.
rvwn SOY
ft. 0 ft• I e ow ro d
5a.Well Location:
ilksTh� s, GG C Ifc, aCi�GJJ
11ft. ? rt. ,� o✓
F'aciiliifylOw'ncrNaamme T Facility -;(ifapplicable) 341,
ft. ft.
�A-e zw/� �r if-Of/4 Ale*.
Physical fL ft.
Physical Address.G-./and Zip
OCt.I. 60. +� 21•REMARKS
roomy Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifecll field,one latilong k sufficient) 22.Certification-
N 6 a9/a
Sign co nificd -omracw Date
6,Is(are)the well(s): ermanent or ❑Tempora C u C
ry'
Br s�nhie this%nrni,l herehr tern hat the uz/!/.il on.c(w'err)lm+.c(rttt'Ied in arrnrdmu t•n'idt
7,Is this a repair to an existing well: OY•es or 15.4 \'CAC O1C.0/00 m•1i.4\'C.4C 01C.1C00 11'elI C'n++suaerinn Stmtdurdi and(ha(a cnpr
thu is a repair.fill oat knnun n-e11 raenrurrinn in(nrumtiro+and e.g+lain the namrc•nl the
n/?his record ha,beer+p,--ided to the well n-c,
repair under:21 reinarkc cecnnn or nn lire hark of this larn+. 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 I GIN*-I is needed. Indicate TOTAL NUMBER of wells (add'Sce Oyer'in Remarks Box).You may also attach additional pages if necessary.
drilled: /A 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -(ft.) Submit this GW-1 within 30 days of well completion per the following:
Fa.....lc etc//s lis[a//depths ifdr/)even((esamp/e-i m_00 and]!ail/00'1
40 249. For All Wells: Original f6mi to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit.1617,MSC,Raleigh,NC 2 7699-1 61 7
1f uater level is shore casing.use
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 Supplv and Open-Loup Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county environmental health department of the county where installed
i
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 Permit Program,161 i MSC.Raleigh,VC 27699-161 I
t
13b.Disinfection type: or, Tabs Amount: 1 1/2 Lbs
i
Form GW-I North Carolina Depanmcni of Environmental Quality-Divivion of Wat l Resource Revised 6-6-20I8
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