GW1-2021-02276_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Barley ' 14.wAT1iR`7ONE5 "
yn,; Y � FROM TO DESCRIPTION �p
Well Contractor Name s` 4y„'�'"'" ft. / ft.
3271-A i(v 21 2021 30% 33k
fL J ors dra`?-O�l�
NC Well Contractor Certification Number
"15 OUTER CAST, fiiF runlh cased ibells OR.EINER tt s""`hcable
-7-.,r��rjl11 �}tli3 FROM TO DIAMETER THICKNESS MATERIAL
B & K Well Drilling Inc t ilatpir i t4' 0 ft. 'ft. 6 1/4 to SDR-21 PVC
Company Name U I JUJ•
O36ANNER CASING.UR TUBING' eotl et mar cigsed Tao
2.Well Construction Permit#• tFROM
TO DIAMETER THICKNESS MATERIAL
- List all applicable well construction permiec(i.e U/C.Cnunty,State.Ynriance,etc.) f4 in.
ft in-
3.Well Use(check well use): N':Water Supply Well: TO DIAMETER BLOT SIZE THICKNESS MATERIA❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) sldenual Water Supply(single) ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) g GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri anon El Wells>100,000 GPD
Non-Water Supply Well: 0 ft- 20 % Bentonite Pour
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation 77777
Tp,SANDlGRAVEL PACK fa h6fik
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT MFTHvD
❑Aquifer Test ❑Stormwater Drainage It. fr.
❑Experimental Technology 0Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer DRILI INGLOG;attacU ddlooaahsheety diierss -`i
FROM TO DESCRiP ON color,hardness,soiVrock ram sL.,etc.)
❑Geothermal(Heating/Cooling/RReturn) ❑Other(explain under/#21 Remarks) % tt S01
4.Date Well(s)Completed: "/ Well ID# /l0 ft, fL rAwg row?7 0 J
IL
D % / Sq1 ' 1
5a.Well Loc •on: /
knq dv G ft. f/ ft A/ Vli
ft ft.
Facility/OwncrNNaamcc Facility/ID#(ifapp icablc)
Physical Add ss,C'ty,and Zip �j ft. It.
IC ZI
o / :3tEMARKS:.iw
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[attlong is sufficient) 22.Certifi ation:
N W
6.Is(are)the well(s): ermanent or ❑Temporary
Si a of rtified ell CeA
Date
B signing this form•I herebyvell ft)xnc(were)ronrtnrcted in accordance with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 15200 Well Construction Standards and that a Copp
ff thia is a repair.fill out knoxot well construction information and explain the nature of the of this record has been provided to the Hr11 owner.
repair under"21 remar•kc section or on the back of this 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 pagelto provide additional well construction info
(add'See Over in Remarks Box).You may also attach additional pages if accessary,
only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwclls
drilled: f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) Submit this GW-I within 30 days of well completion per the followiw•:
For multiple wells list all depths ifdierent(example-3@200 and 2@100')
249. 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 umter level is above casing,use
6.1/18 24b.For Iniecti in
Wells:Copy to DWR,Underground injection Cow rol(TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary
24c.For Water SuDD1Y and Open-Loop Geothermal Return Wells:ropy 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 producine over 100,000 GPD:Copy to DWR,CCPCUA
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13a.Yield(gpm) Method of test:
C a
13b.Disinfection type: bs Amount: 1 1/2 Lbs I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources) Revisal 6-6-201 R