GW1-2021-03470_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey � °�'
14.WATER ZONES i
FROM TO DESCRIPTION
Well Contractor Name n { t• Oft• C• L
3271-A JUN 1 f. ft.
NC Well Contractor Certification Number a [era;es5)ng V�1 15.OUTER CASING for mold cased wells)OR LINER f a livable
B & K Well Drilling Inc ioofm3f10eT,,sef t!011 FROM To DIAMETER THICKNESS MATERIAL.
0 ft. hfs'ft• 61/4 In SDR-21 JPVC
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#' ;7n? Al FROM l'o DIAMETER I THICKNESS I MATERIAL
List all applicable well contra rion permirs(i.e.UIC•Counn•.State. I'arianre.err.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: SCREEN
PP FRONT TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public f[. ft. in.1
i
OGeothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) t. ft. in.
OlndustriaUConimcrcial ❑Residential Water Supply(shared) I •GROUT
❑irri atlon ❑Wells>100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&A>IOUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite Pour
❑Monitoring ORecovery ft. ft.
Injection Well:
❑Aquifer Recharge OGroundwater Remcdiation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRONT TO M.%TF.RIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology OSubsidence Control
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❑Geothennal(Closed Loop) ❑Tracer 2 .DRILLING LOG attach.addidonil sheets if necessary)
FROM I TO DESCRIPTI "(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(HcatingiCooling Rctum) OOthcr(explain under#21 Rcmarks) ft. I i LJ ft.
4.Date Well(s)Completed:f,� �-1 Well ID#
5a.Well Location:
' ft.
oil) f -
Facility/Owncl Vamc Facility
�ID4(ifappplicable)
94Z ^ /(L�LS�iLIr1 Y fL ft.
Physical A ress, y,and Zip ft. ft.
ZO/ 21.REMARKS
Wow
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lifudl field,one lat/long is sut)icicnt) 22.Cert' cation:
- a
6.Is(are)the well(s): ;Zrm.nent or ❑Temporary R ature Certi r ell Con c r D e
Br signigt;this(non.1 herehv r r that the u•elffs)n•as(were)cnnstrueted m arcnrdance with
7.Is this a repair to an existing well: ❑Yes or 15..%'CAC 01C.0100 or 15A AC 01C.0200 Well Cons(ntction Standards and that a cnpv
l(thic is a repair.fil/au knnuvi%ell construction injnrmaiinn and explain the nature nl the n(this record has been provided to the urll nn-ner.
repair under :21 remarks sertinn or on the hack n/'ihis lbrnu.
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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _' (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths i(dflTerea(example-3r&200'and 201100')
40 24a. For All Wells: Original form',to Division of Water Rcsourccs (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 2 7699-1 61 7
/J%,ater level is ahore casing.use
6 1/18 24b. For Injection Wells:Copy to DWR. Underground Injection Control(TUC)
11.Borehole diameter: (in) Program. 1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: Air Rotary 24c.For Water Supply and Open-j
hoop Geothermal Return Wells:Copy to the
(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 producinelover 100,000 GPD: Copy to DWR,CCPCUA
Air Lift Permit Program.1611 MSC.Raleigh,NC 27699-161 1
13a.Yield(gpm) 106 Method of test: `
hlor. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2019
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