GW1-2021-01598_Well Construction - GW1_20210404

ay �
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey I4.'WATER7ONESeq
FROM TO I DESCRIPTION
Well Contractor Name qJ ft ft // (. v(e_ e
3271-A fL /r ft a o7,P'iC-
NC Well Contractor Certification Number IS.OUTER;CASiNG'for moth1.
cased:'S QR LiNPR<da "lieable
B & K Well Drilling Inc !nfii
DIAMETER THICKNESS MATERIAL
I ft. 61/4 i" SDR-21 PVC
Company Name
� FROM
INNER,CASING TO OR.TIJBING, eutl erma7 closed-1uo
FROM ETER K\ESS MATERIAL_
2.Well Construction Permit#: ft.
fL DIAM in•
THIC
List all applicable well construction perm , .i e.WC,Coun(v,Ttate.Variance,etc.)
ft. ft in.
3.Well Use(check well use):
17.SCREEN,..
Water Supply Well: FROM T I DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Mun l/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidenl,.l Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- Bentonite JPour _
❑Monitoring ❑Recovery ft. It.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19,.SAN1D/GRriYEL.PACK fa licalile ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control ft. ft
Geotheal(Closed Loop) ❑Tracer fl:BRILLINGLOG attar;additionallteetsifneeess
❑ rm
FROM TO DESCRIPTION(color,hardness soiVrock e,gritin s,:,etc.) "
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) fL fL
4.Date Well 0 ft ft.
$)Completed: � � Well ID# _
141 fL //i) ft
5a.Well Location: I j�� J 'N
Ge_ �fl/SI!/r�i( .Y6I` ft. ft I
Faci�Ow� � Facility ID#(if applicable) STIL % G/
Physical Address,City,as d Zip w
JY �I ram z•. -
d �
County Parcel Identification No.(PiN) r 4 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific 'on: �)
W^ l;a 0y; �
N W '4{Z��^1,Oi1
Sign of rtified e I Contracto Date
6.Is(are)the well(s): rm eanent or ❑Temporary
By igning this form,1 hereby cert that the nrll(s)was(were)constntcled in accordance with
r'� I A NCAC 02C.0100 or 15A NCAC 02C_0200 Well Construction Standards and that a copy
7.Is this a repair to an existing well: ❑Yes or
this retard has been provided to the xrf!owner.
If this it a repair,fill out know;+well construction information and explain the nature o f the oj
repair under 21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.ForGeoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q� (ft') Submit this GW-1 within 30 days of well completion per the followin^:
For multiple wells list all depths if different(example-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 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
water level is above casing,use"+"
611/18 24b.For Injection Wells:Copy to;DW R,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,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Program,161 1 MSC,Raleigh,NC 27699-1 61 1
tor. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
k
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S