GW1-2021-04688_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey �appwAr,�RZe►NI�s
�70 ft. C fL r.
-•��s, ,. FROM TO_I DESCRIPTION
Well Contractor Name sivwl G 0fr
3271-A ,ay 2 i 2021 ft fL (J/
NC Well Contractor Certification Number G v �ll't1 wills OR LINER Ifli"'"Itcabk "'"
^�r�lCrco,ttt1� 15.UUTER.CASi11G:'formul6 cased. A
B & K Well DrillingInc fiJlti J+` ,^1 FROM TO DIAMETER THICKNESS MATERIAL
tr, ,v . 0 ft. fL 6 1/4 In SDR-21 PVC
Company Name I6.-INNE&CASING OR TUBING eotl erraal elosediloo "S.i
2.Well Construction Permit#: D ///f(7 FROM TO DIAMETER THICKNESS MATERIAL
�^ ft. f4 in.
List all applicable well construction permits State.Variance.etc.)
fL ft. in.
3.Well Use(check well use):
.`SCREEN,• ..
Water Supply Well: FROM TO I DIAMETERSLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mumcr ]/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) srdentml Water Supply(single) L fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.G OU1
❑lrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EM ACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- Bentonite Pour
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft. J
❑AquifcrRecharge ❑GroundwatcrRcmcdiation ,79aSAND/GRAVELPAC1Cifa 'bca ="
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .70RILLING LOG(atticltiddid ni;Iieetsif` "
II'TION color,hardness soiVrock e, rein size,etc.) Y R
❑Gcothcnnal(Hcating/Cooling`R FROM TO DESCR
❑Other(explain under#21 Remarks) fL ft
4,Date Well(s)Completed: 7 / Well ID# ' ft. ft. �6
ft ft A
Sa.Well Location:
ft.
ft. ft.
Facili"Y/0_w.Cfff4amc Facility ID#(if applicable)
C fL ft
fL ft.
Phy'cal/IAdd��ress,City,and Zip /�^� �y
,. Qwtf Zia 7 (//"JG�+/// 2i REMARKS;:'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
fifwcll field,one ladlong is sufficient) 22.Cer eaton:
W
e o e i ell antra r Do
6.Is(are)the well(s): ermanent or ❑Temporary
B .signing hisform,l hc�ehv rt that rhe well(.$)was(were)consrnrctedin accordance xith
7.Is this a repair to an existing well: Dyes or fLTvo A NCAC 01C.0100 or/SA AC 02C.020f1 Well Construction Standards and that a tort
jthts is a repair•fill out knnwvt well construction information and explain the nature ofihe ofthis record has been provided to the well owner.
repair under a21 remarks section or at the back of thts 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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (/� (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijdierent(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Rcsourccs (DWR),
10.Static water level below top of casing:40 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use"+"
6.1/18 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply and Open l-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) Method of test:
Air'Lift Permit Program,161 I MSC,Raleigh,NC 27699-1611
or. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
Revised G-6-201 R
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources