GW1-2021-05717_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD(GW-1) For internal Usc Only:
1.Well Contractor Information: e �
Joseph Bailey "J 14.WATER ZONES
N'cllConti actor Name O ^OQ� FROM TO DESCRIPTION
JUL L L ft. ft. /' G�
3271-A Ulzlt
nro,e._-,!ng fL /0 ft. 7-cc-T rG
NC Well Contractor Certification Number § 15.OUTER CASING for mul -cased, ells OR LINER if op 8cable
IrlS�rn'+a�°on{�
B & K Well Drilling Inc �LnVR Je�h,on FROM 1'O DIAMETER THICKNESS MATERIAL
0 ft. ft. 61/4 in SDR-21 PVC
Company Name Q /� 16.INNER CASING OR TUBING eothermal dosed-loop)
01 2.Well Construction Permit#: 7 3 FROM r0 DIAMETER THICKNESS MATERIAL.
List all applicable+Hell conr.rtructior permits(i.e.UIC.Cal rp.Slate.Tartan,e.etc.) ft. ft. in.
3.Well Use(check well use): ]AW1
ft. In.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mumct "'public it. ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) it. I'L in.
❑lndutitrial/Contmcreial ❑Residential Water Supply(shared) GROUT
❑lrrl ation ❑We]Is>100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 rt Bentonite Pour
❑Monitoring ❑Recovery
injection Well:
rt. rt.
❑Aquifcr Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK if 2pplicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO M.%TERIAI. EMPLACEMENT METHOD
❑Aquifcr Test ❑Stomiwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) :.
FROM TO DESCRN' ION(color,hardness,soillrock e, rain size,etc.)
❑Gcothennal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) 8. ft.
4.Date Well(s)Completed: J t�/ Well ID# WT:93 ft. /O
t.
5a.Well Location: ft. f
' ft.
l4Jt:ny Ti « m0
Faeil /Owner Name FacilitylDk(ifapplicable) ft. fL
��i�-ems ,n�� �ll��✓c. ft. fL
Physics Address,City,and Zip /1
21.RE ft. ft.
MARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.CertifI tion-
N W - Io a 1
6.Is(are)the well(s): anent or ❑Temporary Sig ure of nific We I Contra71".2C.0200
Dad
��� B si,Gnine t tis fnrnr.l herehr e'er' t the erel/(s)u•as(were)constructed io arcnrdanrc with
7.is this a repair to an existing well: ❑Yes or fif�o -.a \'C.4C 02C.0/00 or IS.a A'C Wo/i Constvction Standards and that a cola
if this is a repair.fill out known%ell construction information and explain the nata a of the of this record has heen provided to the well awner
repair under :21 remarks section or on the hack of this fornn.
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-1 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
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9.Total well depth below land surface: 1 [20 (ft.) Submit this GW-I within 30 days of well completion per the following:
Far nudtiple nrcl(s list all depths ifdiQerent wyet plc-3,&,,00 and 20t100')
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing:40 (ft.) Information Processing Unit.1617 MSC,Raleigh,NC 27699-1617
y eater lerel is above casing,use
11.Borehole diameter 6 1/18 (in) 24b. For Injection Wells:Copy toy DWR,Underground Injection Control(iUC)
Program.1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: Air Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.c.auger,rotay,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 Permit Program,1611 MSC.Raleigh,NC 27699-1611
13b.Disinfection type: or. Tabs Amount: 1 1/2 Lbs
Form 6W-I North Carolina Dcpartnmcnt of Environmental Quality-Division of Water Resources Revised 6-6-201 R
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