GW1-2021-00084_Well Construction - GW1_20211109

WELL CONSTRTION RECORD(GW-1)
For Internal Use Only:
UC
1.Well Contractor Information: t:
14..WAEER'Z0r'� pEScrtmTlON i
Joseph Bailey FROM TO �o
fL ft. �`L 1
Well Contractor Name
/ ffi ft.
3271-A tfa 1 >e
EASING'€ot::mUilti cased wells OR',IINER MATERIAL
15.'OUTER" DIAMETER THICKNESS
NC Well Contractor Certification Number FROM TO mi
0 ft PVC
B & K Well Drilling Inc
fc. 61/4 SDR-21
ga :-15:iNNERCASIPiC*:ORT:UBLNG. eoiltettmal HtOsed�i MATERIAL�F
/S /,}') FROM TO DiANtETER
Company Name �y ly Hl ` tn,
C1 ft. ft.
2.Well Construction Permit#: ft.
Gist all applicable wrll consnue•rion permits .e. IC Cmmrv.Score.Varmne e.etc.) ft
3•Well Use(check well Use): 1T:SCREEN DIAMETER SLOT SIZE THICKNESS MATERIAL
FROM TO
in.
Water Supply Weil: ft. tt.
❑Municipal/Pubhc tv
❑Agricultural ft.
❑Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) ft
❑Residential Water Supply(shared) 18*:GROUT h1ATERlAL' EMPLACEMENT METHOD&AMOUNT
❑IndustriallCommercial ovt To
❑Wells>100,000GPD 0 rL 20 fL Bentonite Pour
❑lrri a[ion
Non-Water Supply Well: ft, ft.
❑Recovery
DMonitoring
Injection Well:
DGroundwatcr Rcmcdiation 79 SANDi6ItAYEI PACK'if EMPLACEMENT METHOD
❑Aquifer Recharge MATERIAL
FROM TO
❑Salinity Barrier ft. TO
❑Aquifer Storage and Recovery Dgtormwater Drainage
❑Aquifer Test ft. iL
DESCRIP
(]Subsidence Control "
ad�ttonal':sheets, ;
DExperimental Technology :Zfl Dg1LLING Ltd attacti (c0mr, ardness,sotvrock a in size,etc-)
DTracer FROM To
DGeothermal(Closed Loop)
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, ft- �/�
' � ft. �ft. �i /'� i�9
i r Well ID# ft.
4.Date Well(s)Completed: ! ft.
\ ft. ft. �
Sa.Well Location: d/
- �' d, ft. ft
Facility iII(if applicable) k ft.
Facility/Qwnet Namc
/I ft. ft.
Physical Address ity,and Zip
31s RE?4IiYRKS
21
Parccl identification No.(PiN)
onnty
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I 'FORMATION PROCESSIN
22 Certi lion:
IT
(if well field,one laillong is sufficient)
W
N DateG N
St tare of C ifie onnactor
6.Is(are)the well(s): manent or OTem Porary
13 •signing rhi jorm,/her ehp ceni hat the u•el!(s)was(were)0nnsrn+cred in accordance air
1 A NCAC 02C.0/00 or 1 SA NCAC(12C.0200 Well Crmstrvcrion Standards and that n cop
7.is this a repair to an existing well Dyes or Q�i� this record h0s been prni•ided 10 the well owner.
if this is a repair.fill out known well constru ion infnnnatior+and explain the nave n(the 23.Site diagram or additional well details:
repair under::21 remarks sect or on the back njrhtc jorm-
provide additional well construction
You may use the back of this page to prov info
S.For Geop robefDPT or Closed-Loop Geothermal Wells having the same (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 24.SUBMITTAL INSTRUCTIONS
drilled: 'l1�/ er the following:'
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion p
For multiple wells list all depths ifdifferent(example-3@200,and 2(a)100) 24a. For Ail Wells: original form to Division of Water Resources (DWR),
40
(ft-) information Processing Unit.1617 MSC,Raleigh,NC 27699-1 6 1 7
10.Static water level below top of casing: p to DWR,Underground injection Control(iUC)
if ienier level is above casing,use"+ 24b.For injection Wells:Co y
11.Borehole diameter:
6 1/18 (in.) Program,1636 MSC.Raleigh,NC 27699-1636 p to the
Air Rotary 24c.For Water Su lv and en-Loo Geothermal Return Wells:COPY
12.Well construction method: county environmental health department of the county where installed
(i.e.auger,rotary,cable,direct push,etc-) to DWR,CCPCUA
24d.For Water Wells roducin over 100000 GPD:Copy
FOR WATER SUPPLY WELLS ONLY: Air Lift Permit Program, 1611 MSC,Raleigh,NC 27699-1611
Method of test:
13a.Yield(gpm)_ 1 1/2 Lbs
�JorTabs Amount:
13b.Disinfection type:__--
Rcviscd 6-6-201 R
North Carolina Department of Environmental Quality-Division of Water Resources
Form GW-1