GW1-2021-06321_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information- f,--� I i
Joseph Bailey I-- WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
3271-A vz fL fL
ft ft v1�
NC Well Contractor Certification Number UTER 1K.7DUTER CASING'for cased wells)
TR.IAMETER T
B & K Well Drilling Inc FROM TO At
in. ISDR-21 PVC
0 /()(0 It- 16 1/4
16.INNER CASING OR TUBING Company Name FROM TO DIAMETER THICK-NESS MATERIAL
2.Well Construction Permit#: -3/136
List all applicable well construction permits(i.e.UIC,Counn',State,Variance,etc.) ft fL
3.Well Use(check well use): Of ft. ft in.
17."SC-REENC­­L'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
DAgricultural DMunicipalfPublic ft ft. in.
OGeothcrmal(Heating/Cooling Supply) Oftl5re.tal Water Supply(single) ft fa in.
01ndustrial/Cornmercial OResidential Water Supply(shared)
48.CROUT
Cirrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
OMonitoring DRecovery
Injection Well:
ft. ft.
OAquifcr Recharge OGroundwatcr Rcinediation
SANDIGRAVEL PACK if aptcabIP)
OAquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
ClAquifer Test CIStormwater Drainage ft. fL
ClExperimental Technology OSubsidence Control Af ft ft.
f
.........
013cothermal(Closed Loop) OTracer
FROM TO DE!;CR1PTIJ)N(color,hardness,sontroc in`stett)2
0GcothcrmaI(Mcating/Cooling Return) 00thcr(explain under#21 Remarik-s) 0 fL ft. a
6
a.) W 17yri/'-i
4.Date Well(s)Completed-. Well .# /0 fL n /,ft.
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5a.Well Location: ot") TV ft' (,,wl Iff 0�40V "Ve
)q11wd'V1e' i461br -,—/) ft-
f L a 4/ IYAI17
Facility/OwnerNamc Facility ID4(if applicable)
& C 7v A 44,,A 4U_
Physical Ad*—,Clry,and Zip ft. ft.
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21.REMARKS
of
un,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
un Parcel Identification No.(PIN)
(if well field,one tat/long is sufficient) 22.Cernfiz tion:
N W
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4 QE r f
rtifi�d c of illilt q6 W ell Con
6.Is(are)the well(s): VWr-anent or OTemporary Sign ,r' [tael Date'Al,ligning this fionn.lhereky certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or 15,4 1VC4C 02C.0100 or 15A NCAC 02C,0200 Well Construction Standards and that a cap),
If this is a repair.fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under':21 remarks 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 page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'Scc Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
( i
9.Total well depth below land surface: Ju-5--, —(ft*) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(exaniple:'Y@200'and 2@100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR),
I
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'*+
11.Borehole diameter.6 1/18 (in.) 24b.For Injection Wells:Copy]to DWR,-Underground Injection Control(IUQ
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
13a.Yield(gpm) Q 6AM Method of test:Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
1 13b.Disinfection type: cKior.'Tabs Amount: 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourd% Revised 6-6-20 18