HomeMy WebLinkAboutGW1-2021-04686_Well Construction - GW1_20210521 r
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey t��� I4:wa7ER`7ANES
FROM TO DESCRIPTION
Well Contractor NamerM t, IL
3271-A 4(. p 1 2021 it ft
NC Well Contractor Certification Number lr�K` f+ ` •11� „ p1[TfER(ACING for mnDl'Acasedwells OR Lii!tER d a"ticabk
r �� S Ut R THICKNESS MATERIAL
B & K Well Drilling Inc ,�fa 0 ft ft- 6 1/4 i" SDR-21 JPVC
Company Name
1 � 7JJ 46.,INNEWCANNUPR TUBING eot}iermalclusedauo
2.Well Construction Permit#: v1` J) FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well c-onstruction permits(i.e.UIC.Counfv.State.Variance,etc-.)
ft. ft in.
ft. ft in.
3.Well Use(check well use):
Water Supply Well: FROM I TO IDIAMETER ISLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) tdential Water Supply(single) t it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) A GROUT .,
❑Irri atlon ❑Wells>100,000 GPD FROM I TO "MATERIAL EMPLACEMENT METHOD S AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Bentonite Pour
[]Monitoring ORecovery ft. ft
Injection Well: A/ ft ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation JFRO
RAVEL PACK fa hca6le, -'
❑Aquifer Storage and Recovery []Salinity Barrier TO MATERIAL EMPI,ACEMF.NT MF.TNon
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer INTO DESCR TION a r,hardness,soiVrock run m etc.)
Geothermal(Heating/Cooling Return) OOthcr(explain under#21 Remarks)4.Date Well(s)Completed: Well ID# 0ft ft �5a.Well Location: t /1AnOi /�1G4r1 /4df/mo !T� ft
Facility it)#(ifa applicable) ft. { t
Facility/OtvncrNamc Y PP ) forcle
-
ft, ft
3,40 Roly14/ 1(6 a[�Ir�1��4 ft ft
Physical Address,City,aRaip � ,�// .
'21.REMARKS..•l ,,-
Count;,
� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one lat/long is sufficient) 22.Certification-
re
N H --A ,
e'/1%
6.Is(are)the well(s): ermanent or ❑Temporary
755"A"AFCAC
attire o Certified Well Contra t Da
gning this form,I Jrerebv certi that the uell(,$)was(were)constnected in accon'ance with
7.Is this a repair to an existing well: ❑Yes or CFO 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and t5 t a copy
/f this is a repair.fill out known well construction information and explain the nature of the q/'this record has been provided to the well owner.
repair under :11 remarks section or or 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 construcron info
(add'See Over'in Remarks Box).You may also attach additional pages if t---cessary.
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells
drilled: /,, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:�!!/t, (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 1@100') -
24a. For All Wells: Original form to Division of Water Rcsources (DWR),
10.Static water level below top of casing:40 (ft*) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifuater level is above casing,use
6 1/18 24b. For Injection Wells: Copy to DWR,Underground Injection Coartrol(TUC)
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
(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 producini;over 1OQ000 GPD:Copy to DWR,CCPCUA
Air Lift Permit Program,161' MSC,Raleigh,NC 27699-161 I
13a.Yield(gpm) Method of test:
13b.Disinfection type: Oflor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 R
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