GW1-2021-06323_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey `
p Y _ 14,WATER'2OM
FROM TO DESCRIPTION
Well ContrnctarName l�y*� 'Lax
3271-A �, 15 ,� \& I iG t9 f` OW
Y eY�
NC Well Contractor Certification Number +�QrJ
CQA iS!(1UTRR G;4BmG.farmutt3-rased welts:fiR T;It!7ER cfa`- - ^te 'r
B & K Well Drilling Inc ��tta J°'�„ FROM TO DIAMETER; THICKNESS MATERIAL
.1 n� 0 ft. t ft. g 1/4 in SDR-21 PVC
Company Name
fJf� f�� 16:114-ER�CASINGOR"rFTBiDIG. e6thermala666ll ._-., :
2.Well Construction Permit#: rfji� f FROM I To DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.U1C.County,State.Variance,etc.) fL ft In•
3.Well Use(check well use): Arh ft ft in.
Water Supply Well: 17.'SCREEN '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubhc ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fc ft in.
❑IndustriallComtnercial ❑Residential Water Supply(shared) IS GROUT
❑Im ation ❑Wei is>100,000 GPD FROM To I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. sit ft Bentonite Pour
❑Monitoring ❑Recovery ft. rt
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SANDIGRAS'EL
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To MATERIAL. I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater-Drainage it fL
❑Experimental Technology ❑Subsidence Control tt ft
❑Geothermal(Closed hoop) ❑Tracer 11i':BRILtIiYG'LOG attachY1$tnoual#heetsaiE`'`" '
A
❑Gcothcnnai(NcatinglCooling Return) TO) !❑Other(explain under#21 Remarks) fc. ft DESCRIPTION(color,hardness,soivtk typf,itmin sise,etc.
4.Date Well(s)Completed: �f Well ID# /6�ju ec fla
5a.Well Location: ft ft a
A<A2w r paw r� ft kr ft 11ow �d S
Facility/Owner Name Facility iD4(ifap{ icablc ft. h ft ry
l�lo U'fe IL
6 t c
Physical Address,City,and lip t /r ft t
ill f
31RE1tiIARlzs
q.
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific 'on:
�� N W
6.ls(are)the well(s): 6MPermanent or ❑Temporary Signna rc ofCc ,fled a antractor ; ate
f 8 signing th s jonn.I herehr cart rha to uell(s)was(were)consmicted in accordance frith
7.Is this a repair to an existing well: ❑Yes or IPNO A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature ajthe of this record has been provided to the arll owner.
repair under 21 remarks section or on the back of this farm
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: �] I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /X (ft.)
For nudtiple hells list all depths if dierent(example-3@200'and 2@100`) Submit this GW-I within 30 days of well completion per the following:
10.Static water level below tog of casing:40 (ft.} 24a. For All Wells. Original form to Division of Water Resources (DWR).
ff i,ater level is above casing,use"+" Information Processing Unit„1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter-6 1/18 {in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC.Raleigh.NC 2 7699-1 636
12.Well construction method:Air Rotary i
Zdc.For Water Supply and Open-Loop Geothermal Return Welts:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells Frodurtig over 100,000 GPD:Copy to DWR,CCPCUA
nn Air Lift Permit Program.161 1 MSC,Raleigh,NC 27699-1611
13a.Yield(brym)�v Method of test.
13b.Disinfection type: lor. TabS Amount: 1 1/2 Lbs
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Form GW-I North Carolina Department of Environmental Quality.Division of Water Resources Revised 6-6-2018
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