GW1-2021-06417_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information.
Joseph Bailey
Well Contractor Name FROM To DESCRIPTION
1 11,
3271-A
ilia ft 1'.2)/ f, small't /;:Yf
NC Well Contractor Certification Number
V .45aOUTER CASING`(For Id wvllsl* R.LTNERVEs��bk
B & K Well Drilling Inc 't" np
FROM TO I DIAMETER THICKNESS MATERIAL
0 fL 1 ft- 16 1/4 SDR-21 PVC
Company Name
Nmo
Permit#: top FROM I I G TIJBING-4 ............
ft TO I DIAMETER I THICKNESS- MATERIAL
2.Well Construction P ft in.L
List all applicable�11 construction permits(i.e.UIC,CoUnlY,State. Variance.etc.)
3.Well Use(check well use); A/I+ft. fit.
to
If_:SCREEN:Water Supply Well: FROM I TO I DIAMETER SLOTSIZE THICKNESS MATERIAL
DAgricuitural OMunicipal/Public I,- I r, I in.
©Geothermal(Heating./Cooling Supply) $W.5d`c.u.I Water Supply(single) hOrt. I n, in,
Dindustrial/Commercial DResidential Water Supply(shared)
J&GROUT
OIrrigation 0 Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 Bentonite Pour
DMonitoring ORecovery (L fL
Injection Well: ft. fL
OAquifcr Recharge ClGroundwatcr Rcmcdiation
1 19,SANDIGRAVEL PACK qf4pplicable)
DAquifer Storage and Recovery oSaliniry Barrier FROM TO ft. MAITRIA!1. EMPLAttMENT METHOD
0Aquifer Test ostormwater Drainage fL
OlExperimental Technology OSubsidence Control ft-
0Ge0thermal(Closed Loop) OTracer 'GIOMM" "i"douil A06 if
c4swl
FROM TO DESCRIPTION(color,hardness.soil/rocktype, in AM etc.)
0 cothcrinal(Heating/Cooling Return) 00ther(explain Under#21 Remarks) It. 3W_
4.Date Well(s)Completed: Well ID# RL
ft
5a.Well Location: 1! .50-,o It- Vell,411 &W-147 56.
ft. ft.
2bevd, j?67— 4zkoK RAe- <10 kVV.!5 5elt
ft.
FacilitybwncrNamc Facility TD9(if applicaW) ruel
6� �I-
fL
Owkav? Jr&10
ft. R.T
Physical Address,City,and Eip
ON 5 0
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification:
N W _"/'e' _ /�"
ual
6.ls(are)the well(s): Ver'.1;a. -t or OTemporary Sig urt of ified Well Con Date
Z_g,:i:,_,a 2"v": -Ihai the�vell(s)%)as(were)constnicied in accordance ivith
fionn,1
7.Is this a repair to an existing well: CYes or 15A NC.4CO2C,0100or 15A AfC,4CO2C.0200 Well Construction Standards and that a copy
If is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the xvll owner.
repair under"21 remarks.section or on the hack qJ lft5jornL 23.Site diagram or additional well details:
8.For GeoprobeJDPT 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
9.Total well depth below land surface; 7 Submit this GW-I within 30 days of well completion per the following:
For multiple veils list all depths ildifferent(example-3@200'and 2@100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ffivater level is above casing.use
11.Borehole diameter.6 1/18 (in.) 24b.For Injection Wells:Copy'to DWR,Underground injection Control(TUC)
Program,1636 MSC.Raleigh,i4C 2 7699-1 636
12.Well construction method:Air Rotary 24c_For Water So 2"pd Open-Loopi Geothermal Return Copy to the
(i.e-auger,rotary,cable,direct push.etc,) county environmental health department of the county where inis,11-1ti
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,_0 ):Copy to DWR,CCPCUA
2�G 6EL
Air Lift Pennit Program,1611 MSC,Raleigh,NC 27699 T 11
13a.Yield(gpm) Method of test:
13b.Disinfection type, &6lor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Divmion of Water Rcsourc'CS Revised 64 2018
I