GW1-2021-03466_Well Construction - GW1_20210607

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WELL CONSTRICTION RECORD(GW-1} For internal Use Only:
1.Well Contractor Information:
Joseph Bailey
14.WATER ZONES
' FRUMT 70 DL,SCRIPTION
Well Contractor Name kOUTER
���3271-A ,� 20�� /NC\Nell Contractor Certification Number 04, ft rydcesg111(3 CASING(for multi-cased/wells)OR LINER if o icable
B & K Well Drilling Inc #�C .�}Q r� FROM TO DIAMETER THICKNESS MATERIAL
ICI �is^�Jft0
Company Name 6 ft. 14 ft. 6 1/4 in. SDR-21 PVC
NNW?
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM 1.0 DIAMETER THICKNESS I M•IATERIA1.
List all applicable hell catctracun,,per,iiirs(i.e.WC.Cotain'.Sraw. t itrlanre.ere/ ft. ft. in.
3.Well Use(check well use): AIA
ft. ft. in.
Water Supply Well: 7.SCREEN
FROM I TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Mum al/Public ft. ft. in.,
❑Geothermal(Hcating,'Cooling Supply) es,dential Water Supply(single) ft ft in
❑bidustrial'Commcrcial ❑Residential Water Supply(shared) GROUT
❑irri anon ❑Wells,> 100.000GPD FROM I TO Mt%TERtAL EMIPLACEM1ENTMETHOD&A?COUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite Pouf
014onitoring ❑Recovery fL ft.
injection Well:
rt. rt.
❑Aquifer Recharge 0-Groundwater Rcmcdiation
19.SAND/GRAVEL PACK Elf applicable)
❑Aquifer Storage and Recovety ❑Salinity Barrier FROM TU nIATF.Rint. EMPLACEMENT METHOn
❑Aquifer Test ❑Stormwater Drainage
OExperimental Technology OSubsidence Control ri. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothennal(Flcating,'Cooling Rctutn) OOthcr(explain under 421 kcmarks) FROM ft. I TO DESCRI TUN icninr,hardness.snit/rock type,grain size,etc.J21 )
4.Date ti ell(s)Completed: 070 l Well IN9 vJ kA� ft ft• of ill/,j a(!
ft.
na.Well Location: ,.�j���(� ) ����y
�it1J1�AO&d AN 1.4&y/�aa+ sa+4 �/ ft. I Q ft J
Facility.OwncrNamc Facility ii kk(ifapplicabic) ft. ft.
JIGft. ft.
Physical Addr ss. y.and Zip j� ft.
flf 7 V1I 2I.REZiARK5
County Parcel identification No.(PINT
Sb_Latitude and longitude in degrees/minutes/seconds or decimal degrees:
I it well field.one latilong is suflicienq 22.Certification:
N 1l'
6.ti(are)the weli(s): manent or ❑Temporary'
re of eni d to CV10
r pate
signing hie tarnn.1 heretoat the rrell(si n-ax(--ere),n,,ximcied in arcardaure,rich
7.Is this a repair to an existing well: ❑Yes or �- L9A \'C.aC 02C.0100 or/S. 01C.0.00 Well Construction Standards and that a eapr
/f this is a repair.fit/out knnu�n rre/l catcti tictiai igforma ion and e.cplain the i;aaa•r w 1he al this record Ira,heen prmd we/1 naaer,
repair carder:11 ter»arks section or at the hack nl rhis/)rni.
23.Site diagram or additional Mitell details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the 4inie 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: 24.SUBMITTAL INSTRUCTi6NS
9.Total well depth below land surface: (Or✓ (ft.) Submit this GV1'-1 within 30 days of well completion per the following:
For maltiptc hells list all depths rjdi11erew(.To ph-3&200'and 2;dano)
10.Static water level below top of casing:40 (ft) 2-ia. For All Wells: Original tonn to Division ofWatcr Resources (DWR'),
tf't,x+te+lere!is rrl:avc cati }.nse
hifonn '
ation Processing Unit.1611 MSC.Raleigh,NC-7699-1617
' u "+"11.Borehole diameter: 6 1/1 8 (in.) 24b. For Injection Wells: CopyL DWR, Underground injection Control(IUC)
Program. )636 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,roar},cable,direct push,etc.) county environmental health department of:the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin19 over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Perin t Program.1611 MSC.Raleigh, JC 27699-161 1
Tabs
I3b.Disinfection type: tar. Amount: 1 1/2 Lbs
Fonn UW-I North Carolina DiTiartnient of Em ironmcnia!Quality-Division of Water Resources Revised 6-6-2018
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