GW1-2021-02271_Well Construction - GW1_20210521

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey Y
714:�WAiTERZOI�iES
FROM TO DESCRIPTION
Well Contractor Name
3271-A al ft
ft. ft.
NC Well Contractor Certification Number I5:OU1 ER Gat51PT&#ornlo,cesed:::wells URt'tbTER"rfa <hesble i
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. I qJ* ft 6 1/4 in. SDR-21 PVC
Company Name -
W.'?PMER. ' G:ORB
USING eaffiermsl c1psedada
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS__ MATERIAL
List all applicable well construction permits(i.e.U1C.Cmtniv.State.Variance,etc.) ft. ft in. '
3.Well Use(check well use): ft ft in.
Water Supply
PP y,Well: L��� FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munrci lIT1C� ft ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) fL R. in.
❑Industrial/Cotnmercial ❑Residential Water Supply(shared)
48,GROt3T
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Pour
❑Monitoring ❑Recovery ft ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remcdiation
VA
DlGRAVEL�ACKT 0 tiie
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20 I3RILLiNGIOGfattahlcaddtQonalasheets €'""'
FROM TO DESCRIPTION c lor,hardness,soiVrock e, rain size etc.)
❑Gcothcnnal(Hcating/CoolinguRctum)/ ❑Other(explain under#21 Remark s) ft ft Sal
4.Date Well(5)Completed: / W Z Well ID# D�a-a 16
ft ft r007
ft ft �
5a.Well Loc bon:
(/��Q�^Q ��l / �i�/C7UWi/ ft. ft O
Facility/OwnWd
crNamc pp�f //'�'/ Facility, IDD#(if plicable)) ft. ft
Physical Ad ess, iry,and Zip ft ft
Abft
ounty Parcel Identification No.(PIN)
Information proe,_,s5lnq Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field•one lat/long is sufficient) 22.Certifica' n•
N W "O
6.Is(are)the well(s): ermanent or ❑Temporary Siena of C ifte 11Vn1o, Date
Br igni that the we/l(.$)was(were)constructedin autos/once with
7.Is this a repair to an existing well: ❑Yes or yr` A IJC . orC f12C:0100 Well Construction Standards and t9at a cow
lithiv is a repair',fill out known well constnuction information and explain the nature ofihe of this record has been provided to the xell owner.
repair under`21 remarks section or on the hack of rhir form.
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'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft.) Submit this GW-1 v.ithin 30 days of well completion per the following:
For multiple wells list all depths if dii ferent(ezomple-3@200'and 2@100') ,
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
if watev level is above casing,use-
6 1/18 j Copy sr j 24b.For Injection Wells:Co 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-Loop 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 producing over 100,000 GPD:Copy to DWR,(7CPCUA
/
Air Lift Permit Program,1611 MSC,Raleigh;NC 27699-1 61 1
13a.Yield Om) Method of test:
t3b.Disinfection type: lor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Dcpanment of Environmental Quality-Division of Water Resources Reviq•:d(-6-201 8