GW1-2021-05719_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
FROM TO DESCRIPTION
Well Contiaetot Name
' R� Oft ft, � `��
3271-A RE . ift.
NC Well Contractor Certification Numbet � O 2021 15.OUTER CASING(for multi-cased wells OR LINER'fop livable
B & K Well Drilling Inc FROM r0 DI.A\Itl•ER THICK.ESS M.ATERI.AI.
-IinY 0 ft. 17-7tft. 61/4 in SDR-21 JPVC
Company Name F' ►0>;e..o
3t iQU pp ^L10n 16.INNER CASING OR TUBING eothermat closed-too
irtf:,rtr"���uiZ
Je" FROM 'I"O UTA\IE"1'EK THICKNESS MATERIAL.
2.Well Construction Permit#: r in.Lice all npplirnble+roll rmcctrurrin»p�•rmiec(i.r.G1C.Cnrurnt 5'Inte. !'nriarrd.etrl ft. ft.
ft. ft. in-
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FKO?1 TO DIAMETEW SLOT SIZF. 711ICKNESS I MATERIAL
❑Agricultural ❑Municipal!Public It. ft. in.
❑Geothermal(Healing,Cooling Supply) OResidential Water Supply(single) AOA
I. It. in:
❑htdustriallConimercial ❑Residential Water Supply(shared) 19.GROUT
❑1ITi atlon ❑Wells> 100.000 GPD FROM I TO %1.ATERIAL EMPLACE?tENT METHOD S.A?IO(1NT
Non-Water Supply Well: 0 fI. 20 ft• Bentoriite Pour
❑Monitoring ❑Recovery
Injection Well:
CAquifer Recharge ❑Groundwater Rcmediation 19,SAND/GRAVEL PACK'!'
a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACE?IF.1T Dt F.THUD
❑Aquifer Test ❑Storniwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG(attach additional sheets if neeessa )
4, fft"..
TO DESCRI IUN(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(HcatingiCooling Return) ❑Other(explain under 421 Remarks) ft.
it
I
4.Date Well(s)COmpleted: •ate well ID#
Sa.Well Location:
`Ar jl[/T T / ft, s�
enna : A "'� ft. 1 ft.
Faciliry owncr Namc - Fatcility 1114(il appli ablc)
W4 ,� ft. ft.
ft. ft.
Physical Addr ss,City an Zip
I & *3 /� ' 21.REMARKS
10County / Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if+cell tield,one lat/long is sutticient) 22.Certification'.
�� a
ure f Cen d Weil Cot ractor tc
6.13(are)the well(s): manent or ❑Temporary
r si_�nige this(nett.1 here rertijr that the.rel1/.cl++'ac/wrn0 rm+.VrIla/ed in ar'<'nrdanoe Frith
7.Is this a repair to an existing well: ❑Yes or 15.4 VC.•IC'n2C.010o or 15.J A"C.4C r/2C.()'00 lure//Cnnclrurrion Standards and that a cola-
I,this is a repair.Ill nut +evil rnecnvcrinn in(nrnratirnu and explain the»marry nJ7he
n/this r,,,,rd ha,,been prm'ided to the well mrnrr.
relwir under ;21 rc»nnrkc sec,in»or oft the hack n/ihi.c./nrm. 23.Site diagram or additional well details:
8.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'Sec Oyer'in Remarks Box).You may also attach additional pages if necessaly.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
Fur m»Iliplr yells list all depths it dij%ere»t(rxn»rplc•-3'at_0n'mud_'(p;ron') ,
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
l/order lri el is abort•casing.Ilse"-- i
6 1/18 24h.For Injection Wells: Copy to DWR,Underground Injection Control (TUC)11.Borehole diameter: (in.) Program. 1636 MSC.Raleigh.NC 27699-1636
Air Rotary 24c.For Water Supply and Openl-1 uup Geothermal Return Wells:Co to the
12.Well construction method: Copy
(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 prodacingjoyer 100,000 GPD:Copy to DWR,CCPCUA
I Air Lift Permit Program.1611 MSC.Ralelgli NC 27699-lol l
13a.Yield(gpm) Method of test:
13h.Disinfection type: C tor. Tabs Amount: 1 1/2 Lbs
Fort»CiW-I
North Carolina Department of Environmcrtal Quality-nn islon of Water Rcsuurcci Revised 6-6-201 S
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