GW1-2021-00037_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORDGW-11 internal use only:
CONSTRUCTION
11 Contractor information:
1.We 14.WATERZONES
Joseph Bailey FROM TO DESCUPTION I
f, I ft. e -
Wcl I Contractor Name ft. ft.
3271-A I iz—OUTER G ASMG, nail&. OR LWER MATERIAL
NC Well Contractor Certification Number FROM TO DIAMETERTHICKNESS
B & K Well Drilling Inc 0 f 1. ft 61/4 SDR-21 P.VC:�,:'
.4h
I&JNn� R-CAl OR: 61)
Company Name FROM ft. T ft. DIAMETER in. THICKNESS MATERIAL
Permit#:
2.Well Construction P tion permits(i.e.UIC,C010�v,-�'ole. ....... ft. in.
all applicable well const7.itc.
List.11 applicable-11 con. ft
3.Well Use(check well use): 47;1SCRIEEN1- THICKNESS MATERIAL
FROM TO DIAMETER SLOTSIZE
in.
Water Supply Well: ft. ft.
'y Well:
M 1/Public
IC n in.
ClAgricultural U oq;�,�sidentiall Water Supply(single) ft.
ea
C
0G,Othermal(Ijeating/Cooling SUPPIY) oResidential Water Supply(shared) UT
CEM METHOD 1&GRO j%.&TERIAL ENT METHOD&A OIJNT
7 EMPLA
0 b omon
lildustrial/COmmerrlal 0WeIIS>1 o0,000 GPD FROM TO Pour
C❑
0 1 ft. 20 ft. Ben ni e
]Irri ation
Non-Water Supply Well: ORecoverY ft. ft.
0M011itoring
Injection Well:
ClGroundwater Rcinediation 19 NDI VF1
[]Aquifer Recharge [3 Salinity Barrier FROM TO MA IAI.
0AqUifer Storage and Recovery [3Stormwater Drainage ft. t.
0 Aquifer Test ft. ft.
oSubsidence Control
a'
Experimental Technology �,ttieh,idditi sl
C3 oTracer .70,DRML.AN6.C DFSCRI O\. soil/rockrypegra
..FROM TO (color,hardness,
DGeothermal(Closed LOOP) o0thcr(explain under#21 Remarks) ft. ft.
Mcotlicn-nal(1-1catillg/Cooling Return) - ft. ft d'm
QJ
1)
4.Date Well(s)Completed: Well ID4 ft. ft. fd
5a Well Location: ft ft.
�cility im(if applicabl,c) ft. ft.
le ft fit
Facility/ownerNarric
e P
Alr
04
'n ft. ft
Physical Ad C' and Zip ZI REMARKS::?
Ity,
4&
paccl Identification No.(PIN)
County
ngitude in degrees/minutes/secondi or decimal degrees: 22.certification:
5b.Latitude and lo
(if well field,one lat/10ng is sufficient) W
------------- N Date
St ure Of nice onrractor
I- 07remporary - at the (were)constructed in accordl
6.ls(arc)thewell(s): vg—..ent or B signing thisficrin.I herehi,cert and that I copy
15A NCAC 02C.0100 or ISA NC AC 02C.0200 H'ell CM'strl Standard"
7.Is this a repair to an existing well: OYes or () this record has been provided to the.well ow77er
if this is a repair,fill Out known well construction information and explain the
name nl the it or on the back of this for- 23.Site diagram or additional well details:
pag You provide additional well construction info
repair under i:21 remarks sectiO You may use the back of this ' e
8.For Geoprobell or Closed-Loop Geothermal Wells having The same (add'See Over'in Remarks Box).; may also attach additional pages if necessary
construction,only I GW_l is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled: 1A< ..—
) (ft') Submit this GW-I within 30 days of well completion per the following:
9.Total well depth below land surface:
(examPle-3@200'and 2glUv) Original;form to Division of Water Resources (DWR).
For natliple wells list all depths if all 24a. For All Wells: 0 . MSC,Raleigh,NC 27699-1617
40 (ft-) Information—Processing Unit,1617
10.Static water level below top of casing:
--------------- o DWR,Underground injection Control(IUC)
vote,-level is above casing,use'*+" 24b.for [niection_��ells:COPY t 27699-1636
61/18 Program,1636 MSC.Raleigh,NC
1.Borehole diameter: Wells�i COPY to the
)Geothermal Return we
Air Rotary 24c-For Water Su id 0 e,- "P-��
12.Well construction method: county—environmental health department of the county where installed
(i.e.auger,rotary,cable,direct push,etc-) I CCPCUA
24d.For Water Wells I oducino over 100,000 GPD:Copy to DWR,
FOR WATER SUPPLY WELLS ONLY: PC-n,1Tljt PTOg m,1611 MSC,Raleigh,NC 27699-1611
13a.Yield Gopm) Method of test:
Air Lift 1 1/2 Lbs
11-6hior. Tabs Amount*
13b.Disinfection type:-- ------_ i Revised 6-6-2019
North Carolina Department of Environmental Quality-Division of Water Rcs?:Urccs
Form GW-I I