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HomeMy WebLinkAboutGW1-2021-05719_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 i I ri