GW1-2021-02269_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
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Joseph Bailey . " 14FwArERzoxFS
'"�!!�Et—,- FROM TO DESCRIPTION
Well Contractor Name +' �u,.e 4•_- A ft. / ft J Lt-10
3271-A i,AY 21 2021 3Vpft 333,
I ft j elf arc�OeV
NC Well Contractor Certification Number unit ',15.OUTER GASP fof nalU-ca5ed,Vvells•OR INER If;a `luable -
B & K Well DrillingIncfogyYGCB �� FROM TO s DIAMETER THICKNESS MATERIAL
E n3 0 ft. ft. 6 1/4 I" SDR 21 PVC
Company Name u t �•„•...,
O 16.iNNER•CASING OR.TUBING' 'euilierma7 cl6sedaoo
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
- List all applicable well construction permits(i.e.U/C.Camty.Stale.Vnrinnce,etr.)
ft. ft. in.
ft ft in.
3.Well Use(check well use):
Water Supply Well: FROM I TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) sldential Water Supply(single) AAI#L
ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) g,;GROIIT ->
❑irri ation ❑Wells>I00,000GPD FROM TO MA IAL TER EMPLACEMENT METHOD&AMOUNT
^
Non-Water Supply Well: 0 ft- 20 fL Bentonite JPour
❑Monitoring ❑Recovery ft. ft
injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Rcmcdiation I9. AND/GRAVEL` ifa lica6tE "`
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAI. F.MPLACFMENT MF.THCrD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer DRILI INGIOG attactisddlffoniitdheetsiLliie'eels.FROM TO DESCRn' ON(color,hardness,soiUtrock e, rain st:,ete.)
❑Geothermal(Hcating/Cooling�RRetuml) ❑Other(explain under#/21 Remarks) ft b ft 50!i'
4.Date Well(s)Completed: 7 J Well ID# O ft. ft n�'
ft D ft.
5a.Well Loc —
rG ft. y fL
Fact]ity/Owner Name Facility lD#(ifappieablc) ft ft
fL ft.
Physical Add ss,C'ty,and Zip
_J-y'
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certiti ation
N y!
�IA I a/ yh/4;/
6.Is(are)the well(s): ermanent or ❑Temporary
Si a of rtified ell V Date
B signing this form,I herebat the rvell(.r)n•as(were)eonstntcted in act ordmtce with
7.Is this a repair to an existing well: ❑Yes or ISA NCAC 02C.01(I(l or 152C.0200 well Construction Standards and tkat a cops-
)f this is a repair,fill out known well construction information and explain the nature nf'the of this record has been provided to the nrll owner.
repair under"21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/Dl'T or Closed-Loop Geothermal Wells having the same
(add'See Over in Remarks Box).You may also attach additional pages if accessary,
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells
drilled: f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple ire/ls list all depths ifeli ferent(example-3@200'and 2@100') Submit this GW-1 within 30'days of well completion per the followi"•::
249. For All Wells: Original form to Division of Water Rcsourece (DWR),
10.Static water level below top of casing:40 (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f water level is above casing,use
6.1/18 24b.For injection Wells:Copy to DWR,Underground injection Comml(TUC)
1.Borehole diameter: (i") Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:t:opy 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,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Cabs Amount: 1 1/2 Lbs
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 R
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