GW1-2021-02277_Well Construction - GW1_20210521

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
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1.Well Contractor Information:
Joseph Bailey 14:1WATER7.0NES
Well Contractor Name
��� FROM TO DESCRtPT10N
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3271-A �lz� V It ft G
c: TOCL'BS'0� fL fL
NC Well Contractor Certification Number ifi1S�T1 �ci0 CG^Y'OB
ptu�>iZ„ w,]5:UUTER CASING formulticased„wells OR GiNER it a 110'luabte :..
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. "
ft. 6 1/4 in- SDR-21 PVC
Company Name
�,( &INNER CAS G' TUBING e6thermal ciosed Too
2.Well Construction Permit#: ') FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County, tote.Variance,etc'.) ft. ft. in.
ft. ft. ! in.
3.Well Use(check well use):
'-]7."SCREEN
Water Supply Well: FROM I TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Mumct blic fL m in.
❑Geothermal(Heating/Cooling Supply) sidentiai Water Supply(single) ft n, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&A MOUNT
Non-Water Supply Well: 0 % 20 fL Bentonite Pour
❑Monitoring ❑Recovery ft ft.
injection Well: IL ft.
❑Aquifer Recharge ❑Groundwater Remediation
]9*S:4ND/GRAVEL PACK r4'� lrcatile ''
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage I
ft. ft.
❑Experimental Technology ❑Subsidence Control L ft.
DGeo[hermal(Closed Loop) ❑Tracer 20 DRILLINGIAG(attael addifioaali3heetstfiie"
FROM TO DESCRIPTION color.hardness,soil/rock yp 4 ram size,eta
❑Gcothcnnal(Hcating/Cooling Return) ❑OUter(explain under#21 Remarks) D tL ft
/ 2 -i a
4.Date Well(s)Completed: Well iD#�( ( 0 ft. lift / U
5a.Well Location:
ft. fL
Facility/OwncrNamc Facil'y iD#(if applicable) ft t
CLGa�/ 7td ft. fL
C +
—r ft. fL
Physical Addre Cif and Zip J� f
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certificati `
N W ,
Siga ofaied ell Montractor Date
/60/
erma
6.Is(are)the well(s): nent or ❑Temporary
Br igning this form,I hereby rert6 that t it-ell(.$)%,as(were)c•onstriieted in accnrGaitce with
7.Is this a repair to an existing well: ❑Yes or SN_a—� 114 NCAC 02C.0100 or IBA NCAC 01C.0200 Well Construction Standards and vmi a copy
If this is a repair,fill out knnxni well construction information and explain the nature of the of this record has been provided to the xr11 owner.
repair under"21 remarks section or au the back of this form. 23.Site diagram or additional well details:
You may use the back of this page;to provide additional well construct:m info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'See Over in Remarks Box).You may also attach additional pages if t.ecessary.
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
Fa'multiple wells list all depths ifdifferent(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 (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/(water level is above casing,use"+"
611/18 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-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
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) QQ 64fll Method of test:
13b.Disinfection type: Chl . Tabs Amount: 1 1/2 Lbs
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources! Revised 6-6-201 R
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