GW1-2021-06320_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information: tw }
Joseph Bailey � �
14.Wr1TER:ZONES ,.
Well Contractor Name _ FROM TO DESCRIPTION
3271-A �;�P 1 �02 Ul f L � IL ft � 'I
fL
' r�,-3��� p md
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NC Well Contractor Certification Number p s� 0,
B & K Well Drilling Inc 1iiS t� 3�y10,J r'�,On FROUTER TSf1�lG'forifl D AMET wells)ORHICKNESS g MATERIAL
ft. ft. 6 1/4 i in. SDR 21 PVC
Company Name �t
►IP ?\(9 l��w 26.`,I3V iER-CASING OR TQBWG: eothe al cl ised-foo ., ..
2.Well Construction Permit#: c l7 e) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.Connrv,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ,4 ft. ft in.
Water Supply! 17.SCREEN
FROM TO V DIAMETER i SLOTSIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft ft. in.'
OGeothermal(Heating/Cooling Supply) sidential Water Supply(single) ft ft. in,
Dlndustrial/Commercial DResidential Water Supply(shared) 18 GROUT
01rri ation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Pour
DMonitoring ❑Recovery ft. ft
injection Well:
❑Aquifer Recharge DGroundwater Remediation
19:SA1ND/GRAVEL PACK if s 'cable
DAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT NIETHOD
DAquifer Test OStormwater Drainage ft ft
0Experimental Technology ❑Subsidence Control ft. ft
DGeothertnal(Closed Loop) OTracer 240:DRILLINGLOG attach idditional-sheets"if ueeessa
G a in size,etc.)
Gcothcnnal(HcatinglCooling Return) OOther(explain under#21 Remarks) � ft. jU ft �
FROM TO DESC PTION(color,hardntss,sail/rock i
Oil
4.Date Well(s)Completed: �ai Weil ID#/__10/ d ft
ft. ft.
5JIa..Well{Location:
~ t'.)t4•F�J�Y/�_f,�'�� � � ��6��d•/.. ft /i ft
Facility/OwncrNamc Facility 1D#(ifarp�plliicaa�ble) ft.
1O I�� alit Intld�tli l 0 AC Sr±ZM�! ft
'7 ft
Physical A ress,City,and Zip `� ft ft
f t b 3 aF-_1/-/D/iJr 21:REMARKS
�/ ;.
ounty 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
A4 /-Z -X/I
6.ls(are)the weli(s): .anent or OTemporary Signa a of Ce fled ell ntractor Date
Br, ning this faun.1 hereby certify that the wells)was(were)constructed in accordance with
7.is this a repair to an existing well: Dyes or 15A NCAC 02C.0100 or I5A NCAC 02C-0200 Well Construction Standards and that a cony
If this is a repair.fill out known well constnuction infornnation and explain the nature of the of this record has been provided to the well owner.
repair under=21 remarks section or on the hack oJ7his form.
23.Site diagram or additional well details:
&.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: j 24,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —00 Submit this GW-i within 30 days of well completion per the following:
s. for mu��iole wells list all depths if different(example-3L7a 200'and 2L100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ftJ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
If water level is above casing,use•+•• i
11.Borehole diameter:6 1/18 (in.) 24b•For injection Wells:Copy jto,DWR,Underground Injection Control(IUC)
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 Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: j
C or. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourlces Revised 6-6-201 R
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