GW1-2021-07287_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD GW-1 �� For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey ) '1� n 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name ^ /gobfit. ft. ,rU10
3271-A t
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�p ��, ' ft_10 . ft. _SAull gyV e...
NC Well Contractor Certification Number �� v�� 15.OUTER CASING(for multi-cased welIs)OR LINER if a ti able
B & K Well Drilling Inc O FROM TO DIAMETER THICKNESS MATERIAL
r' 0 H. I1t. 6 1/4 i" SDR-21 JPVC
Company Name ^/� r`] 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: �Je `�`7vj FROM I'o DIAMETER THICKNESS MA A.
List all applicable we11,nnsnvction permits(i.e.UIC.Cnturm State.i'arim+re,el('.) ft. fit. in.
tt. tt.3.Well Use(check well use): in.
17.SCREEN
Water Supply V4'ell: FROM TO UI.AMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothetmal(Heating/Cooling Supply) sidential Water Supply(single) t. ft, in.
❑hidustrial/Commercial ❑Residentiat Water Supply(shared) 18.GROUT
❑liTi ation ❑Wells>100.000 GPD FROM I TO A1.%TERIAL EMPLACEMENT METHOD g AMOUNT
Non-Water Supply Well: O a• 20 a• Bentonite Pour
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remcdiation
19,SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO aLATF.R1At. F.MPLACRMF.NT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach.additidnal sheets if necessary)
FR011 TO DESCRt TIUN(valor artiness,soiUrock e,grain size,etc.)
❑Geothermal(Ftcating/Cooling Return) ❑Other(explain under#21 Rcmarks) fi ft
4.Date Well Completed: Well ID# ft. ft. ie
19
ft. T ft. t alls rAm ry i
5a.Well Location:
ef% erl9�S L ft. ft.v
FlaaliryT /O N u aciiit k(itapplicable) fit. fit.
If.
• � fL fit.
PhE�k
Address. ity,and Zip
,� 0l1 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certification,
L
N p
6.Is(are)the well(s): anent or ❑Temporary Sr, t of rtiticd ContI
r
8 signing this Jbrar.l herehv u vetat the rl/0)was(were)consiracted io accordance with
7.Is this a repair to an existing well: ❑Yes or I .d.\'CAC 02C.0100 or 15A A' OZC.n'on It'el/Cnncnveria+Sraudardc a+d that n cnpt
J this is a repair.,Jill out knnev+well cnnuruerinn infnrumtiar and explain the Piano 'the
this record has been provided to the well nearer.
repair tinder 21 remarkc sertion or on the hack 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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: aft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wc•/1s list all depths rfdijferent lesanrplc- ru,2 0 and 2(g)100')
40 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: aft) Information Processing Unit,1617 MSC,Raleigh,INC 27699-1617
1f+rarer level is above casing.use"+••
6 1/18 24b.For Injection Wells-Copy,to DWR.Underground Injection Control(IUC)
11.Borehole diameter: (in•) Program. 1636 MSC,Raleigh.INC 27699-1636
12.Well construction method: Air Rotary 24c,For Water Supply and Open-hoop 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
Air Lift Permit Program.1611 MSC.Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: CA fl or. Tabs Amount: 1 1/2 Lbs
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 R
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