GW1-2021-06513_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD (GW-1) Fo41ntem-alUse Only:
I.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
FRU>1 TO DESCRIPTION
Well Contractor Name /J ft. /- ft. v
3271-A 7 ft. 4.(.Tu rG 6n
NC Well Contractor Certification Number 1r3r OUTER CA iNG for m^ti-cased wells OR LINER i(alicable
B & K Well Drilling Inc FROM 1'n DIAMETER fHIC-21 MATF.RI.AL
p rt. ft. 61/4 i'• SDR-21 JPVC
Company Name 16.INNER CASING OR TUBING eother at closed-loop
FROM 'I'U DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft.
List all applicahle well cnn,ca�ucfiar permit.,(i.e.i IC.Cni mm Stale. Pariam e.etc.I
3.Well Use(check well use):
N ft. ft. I in.
17.SCREEN
Water Supply Well: FROM I TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Munro Public ft. ft. in.
❑Geothermal(Hcating/Cooling Supply) sidential Water Supply(Single) ft. fL in.
❑Industrial-Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation El We[Is> I00.000 GPD [19.
RO>I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 20 ft Bentonite POUF
❑Monitoring ❑Recovery ft. ft.
injection Well: R, ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiatioo SAND/GRAVEL PACK if a itcable
❑Aquifer Storage and Recovery ❑Salinity Banner FROM TO M.% ..RI AI. F.MPLACF.MEN'T METHOD
❑Aquifer Test ❑Stormwater Drainage R. ft.
❑Experitnental Technology ❑Subsidence Control A14
ft. ft.
❑Geothenal(Closed Loop) ❑Tracer 20.DRILLfNG LOG attach additional sheets if necessary)
FROM TO DESCR TION(color,hardness.soil/rock type.grain size,etc.)
❑Geothermal(HcatingiCooling Return) ❑Other(explain under#21 Rcmarks) ft. ft. C s6i
4.Date Well(s)Completed: Well ID# � �
5a.Well Location: w
FaciIitviOu'net Name FacilityT (ifapplicable)
Ilk
► Q-�✓� /fit �lGi9 /ilk H. ft.
ft. ra
Physical Address.Ci and Zip o
Y � 21.REMARKS
A' r
`= Parcel Identification No.(PIN)
('a,nry
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �TIO,t� ,I3
(it'u•cll field,one latilong is sufficient) 22.Certification: {'�C �Nr] ��r,'(+On
N W 1�
.i azure of eni t 'ell Cont ctor Dat
6.Is(a're)the well(s): ermanent or ❑Temporal-}•
Y^V .s. ....,. ..i.c/a'nr./herehr rti/i dm(the u'elI(.d,'ns(war¢)c nn.ctructed is arrnrdanre u'i1/r
7.is this a repair to an existing well: ❑Yes or SA\C 4C 02C.010O or/SA -C•aC O2C.0_'OO If'c•li Cnustnrctiat.Standards and ilicrt a copy
if this is a repair.Jill out known well construction information and explain the nature of the nl this record has heen provided ro the w•e/l ou-ner.
repair ruder=11 remarks section or oil the hark of Chic joint. 23.Site diagram or additional well details:
3.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'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1,;20,57 (ft.) Submit this GW-1 within 30 days of well completion per the following:
Fur multiple,'ells list all depths if different lo.w pie- I-..200 and 2(d.100')
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Water Rcsourcos (DWR).
Information Processing Unit,1617:MSC.Raleigh,NC 27699-1617
lJlruter(aril is,hare casing,use"+" �
6 1/18 24b. For injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
l 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 producin,over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Permit Program,1611
MSC,Raleteh,NC 27699-161 I
for Tabs 1 1/2 Lbs
.
13b.Disinfection type: Amount:
Form CiW-1 North Carolina Department of Envinmmenial Quality-Division or'Water Rcsour�cs Revised 6-6-201 R