GW1-2021-05431_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER 70NES
FROM TO DESCRIPTION
We]I Contractor Name it- ft.
3271-A
5-
NC Well Contractor Certification Number
?Tor 15.0: R:CASFN 0 u �cdsed'. 5 LMR
�essl MATERIAL
B & K Well Drilling Inc �4 0 mom TO DIAMETER THICKNESS
, jjj Sed1011 6 1/4 SDR-21 PVC
Company Name
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 50910, fL in.
List all applicable well construCtiol,permits6-e UIC,County.State.Variance,etc.)
ft- In.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ElAgricultural OMunicipal/Public IL ft. in.
oGeotheffnal(Heating/Cooling Supply) idential Water Supply(single) A* rt. in.
01ndustriallCommercial oResidential Water Supply(shared)
IS GRO
Oirrigation r7l Wells>I 00,000 GPD FrtoM TO MATERIAL EM PLACEMENT METHOD&AMOUN I
0 20 IL Bentonke Pour
Non-Water Supply Well:
Olvionitoring DRecovery tt. ft.
injection Well: V11 f I.
ElAquifer Recharge ❑oGroundwatcr Rcinciliation
19;'SAN"DI . VEL PACK 'cable
DAquifer Storage and Recovery DSalinity Barrier FROM ft. TO fL MATERIAL EMPLACEMENT METHOD
0 Aquifer Test oStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control
20,DR1LLrNG*L0G attach-aditionat S6�&if
oGeothermal(Closed Loop) GTracer -min size,etc
LOGcothermal(Hcating/Cooling Rctum) 00ther(explain under 421 Remarks) FROM ft. TO DESCRITPON(color,hardness,soivrocl(fype�
16)'t. A
4.Date Weil(s)Completed: 1 v WelllD# ft.
fin G
ft. t
5a.Well Location: ft. ft.
K -1— 1 /_
vr fL
Facility/Owncr Name Fw ft ft.
saw li A ,
ft. ft
Physical Address, and Zip � 1,..RE ' . I . 1. . ... _7� I.,
ell e"'i 2&,rG� 1 NAR
Cou—nty Parccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certification:
N -W
fie We Date
Si r f ifie e Contracto
s)h."he
6.ls(are)the well(s): CL106'rmanent or OTemporary a n lber liell(s),,05(were)constri,credin accordance,,irli
B signing thLv fornn.I herehy coati I at
or 5, 1 11 Cojislywc1ion Standards and that a copy
7.Is this a repair to an existing well: E3Yes or A NCAC 102C.0100 or 15A MC C 02C.0200 Nfle o
If this is a repair.fill out knomi%,ell,onsiniction information and explain the nature n0he of this record has been provided to the well ow ier.
repair under.121 remarks seciinn,or on the back of thisjorm 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having Elie same You may use the back of this page to provide additional well construction info
(add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
construction.only I GW-I is needed. Indicate TOTAL NUMBER of wells
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 njulaple veils list all depths if differenl(example-3@200'and 2@1001 24a. For All Wells: original form to Division of Water Resources (DW­R)_
10.Static water level below top of casing:40 (ft.) information Processing Unit.1617 i MSC,Raleigh,NC 27699-1617
1f ante,level is above casing,use 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:6 1/18 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
Air Rotary 24c.For Water Supply and Open�Loop Geothermal Return Copy to the
(i.e.auger,rotary.cable,direct push,etc.)
Wells:
12.Well construction method: county environmental health department of the county where inT.-fin:
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing'over 100,000 GPD: Copy to DWR,CCPCUA
Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
Air Lift ift
C11f
13b.Disinfection type:
or. Tabs Amount: 1 1/2 Lbs
North Carolina Department of Environmental Quality-Division of Water Rcs;ource s Revised 6-6-2019
Form GW-I