GW1-2021-06324_Well Construction - GW1_20210915 (4)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
4
1.Well Contractor Information:
Joseph Bailey 14:WATER.Z0Nn
FROM TO DESCRIPTION
Well Contractor Name
3271-A � fL 9� fL
(L fL
NC Well Contractor Certification Number 15,OUTERCASING for'Itilti-cased.weUs OR LINER;if.a Ircable::::
B & K Well Drilling Inc FROM TO DIAMETER; THICKNESS MATERIAL
0 ft. `fL 61/4 in• SDR-21 PVC
Company Name �� ` d :-
//)5 1bi ETHERCASING'OR'TUSIId6 `eoBtermaliclosed laa :-
2.Well Construction Permit#• FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well consnverion permits(ire.UIC.Counn,.State.Variance.etc.) ft ft. in.
I i
3.Well Use(check well use): fL ft. in.
Water Supply Well: IT SCREEN
Pp Y FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Munici blic fL 2 in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL I
in.
❑Industrial/Commercial ❑Residential Water Supply I (shared) I&,GROUT
❑im ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Bentonite Pour
❑Monitoring ❑Recovery ft. fL
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remcdiation
]9.SANDfGRAXEL PACK-Of '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL F.MPLACFMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control fc fL
❑Geothermal(Closed Loop) ❑Tracer 26.'DRILLMGLOG:attachailditloual shee&W.'
FROM TO DE,SCRIP O\(color,hardness,soil/rock e, n svx,etc.)
❑Geothermal(Heating/Cooling Return) I❑Outer(explain undccr#21 Ranarks)J D fL fL e o
4.Date Well(s)Completed: iJ I Well ID# X v ft ft
ft. ft.
5a.j�Weelll Location:
ooca'on::� �t �,/J
/1y+�1 LptJ� �� C hill*1511 ff IS- ft. tJs ft
Fac/illiitty`/OwnerNamc4 acilityll4(i appliic,1a/b/hc) '9) ft. 7 fL /
I t/U i� �f'Je, l�/dOreSUi/e r� ft. ft �,
Physical Addr ss,City,and Zip fL fL F
re/ �I P TO 0 O -fY r! ._J (/� Z]RR1 MARKS::
15
County Parcel Identification No.(PIN) Uri
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
t iO11
(ifwcll field,one IaUlong is sufficient) 22.Cer-fication• fJ"`"u-o n'Q �`ran CJ`P(',1•
N W
6.Is(are)the well(s): ermanent or ❑Temporary Si urc f Ce ' Well nttac:or D
i�signing rhLs form.:her •cer1 n that the ell(s)wns(were)cnnstnrcred in accordance with
7.Is this a repair to an existing well ❑Yes or SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
this is a repair.fill out knonm well construction information and explain the nature n/'the njrhis record her been provided to the well owner.
If
repair under"21 remarks.section or on the hack 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 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-I within 30 days of well completion per the following:
For multiple tselLs list all depths ifdiereni(example-3@200 and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DR).
10.Static water level below top of casing:40 (ft.) WInformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ill raier level is above casing,use"+'•
6 1/18 24b.For[niection Wells:Copy Ito,DWR,'Underground Injection Control(TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
Air Rotary
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal ReturMale
lls:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where d
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin19 over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
tor. Tabs 1 1/2 Lbs
Amount:
13b.Disinfection type:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rcsourc's Revised 6-6-2018