GW1-2021-00217_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD GW-1
For Internal lisz Oni��:
I.Welll'Contractor Information:
14 WATERZOnES DESCRIPTIUN
Joseph Bailey I FROM ft. TO e
��J ! i
Well Contractor Name �ft ft j r
i . i '. i
3271-A "`s61c)
15.OLTER C4SIN-G(for mold cased Wells)OR LTNER if a v1 aTERIAL __11 �
THICKNESS
NC We Ccnihcation Kumbcr
FROM TO I UfA>t ETER i�_
B &;K Well Drilling
Inc o f ft. 6114 in. SDc-
16.IN?1ER AS OR 7IIBLTIG(geothermal lcHlCK�ESs ! nt tTERUL
UL4?•IETER .
Compally Name 7 "t), j ( FRO TU —
y J in-
! ft I f[. �
2,Well Construction Permit#: I
fL tn- i
ft. I
List nIi'applirnhle well rnnsuucno❑permrr.li.r.GIC.Cm+nn•.Score.t m m„� rf r
11.SCREEN .11
M_47 F,RIAf.
3.Well Use(check well use): FROM TO DIAMETER SL SIZE THICK1E55
r ft
Watei,Supply Well: ft. i
0.iv1uniclpal'Public I n
DAerecultural 1\ aiu;lel ft ft.
1 Residential Water Supp,'(- _ J---
DGeothermal(Heating/Cooling Supp y) I (shared) EMPLACE?1 ENT METHODS��101;'*T !
❑Residential Water Supply( 18.GROUT TO \I�TERL\L
Dlndtistrixl/Cotnrrtercial FRo?f Pour — --'
O\Vells>100.000 GPD O H, I 20 ft• IBentonite _ }
Otrtiea[ion
ft
Non-Wa ter SupPly Well: ft. !
❑Recovery
D?vlonitoring ft. +
ft. 1 J.
Injection Well:
nGroundwatcrRcmcdiauon 19-SANDIGR4 ELPACK ifaT}1R'abte F\1Pi.nCEatF.�T>tETH(�--,
DAgylfcr Recharge
FRII 7T_—.�--- - i
i�Saliniq'Barrier ft,
CA'ulfer Storage and Recovery ft.
rSlotrriwater Drainage
I ft.
p 4quifer Test ft,
-Subsidence Control
DIL
RLING LOG(attach DES tc.l I CAne^lornhardne soivrock n e.grain srae.e
OEzperimental Technology 20. I
DTracer FROM TO
DGeothennal(Closed Loop) la I 1 ft I' /f) ft. I !fr tie;( j
DO[hcr(expin under=21 Remarks) /
DG`cothcnnal(Hcatin�CoolingRctum) I /G ft
- Well 1D# i .(�I
C.
.} -
,Date Well(s)Com pfeted: ft. i ft.
ja.W'ell Location:
Z � /f[. � >�;i ft. �•r,--t.t �:=4.� =iJ/d, .v '1 �--'.
/ i ft.
ell i iian'rcahic
FaciUty 11)'( P l
Facilit}•: ncrNamc
I
Plisieal A dress,City.and Zip 21�A6 —
lrll
I
_.
r GJ „�1,F�Ii�,ar���
Parcel identification No (Pitt)
1;,:.
County
22.Certif 5tton:
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lif Well field,one tatflong is sutlicicnt) INN
c
N ...a'i,ed `ell C ntra,or
Sig amrt o
m!,ctrrc'ad m arrnrdcnrd•r:!f:
Tern orar)' n.1 hcreM' «7i!hal file,re1110 Was(µ'erei r
6.Is(are)the well(s): rmanent or G P wr,u;•c fibs for nzC.ri'firi It Cnna,ucnnn Standards anti!ha!a n;n'
1;4 vCACo?C.rii;uia'o,i : C•.0
9;!Is this a repair to an existing
well: II or o o;Ilti.c record has heen Pro, fo the t ell nu per.
r this fm'n,, 23.Site diagram or additional well details:
1(fius is a repair.(IJ out known•ea'(1 cnaarucdnn mjnr,nutiou and erry'oin rira,move ni r"e use the back of this pace to provide additional%well construction rnfu
'repmr under:: (remorks.cedinn a•on the hark n. You May
$.For GeoprobelDPT or Closed-Loop Geothermal Wells hating the same (add'Ste Over'in Remarks Boxl.You may also attach additional pages if necessar,✓.
4construction.OrI 1 GW-1 is needed. Indicate TOTAL NL'?`'1BFR of',vc!Is �� SL1$4ttTT.A L INSTR_ L�CTIONS
iirilled: �� (ftJ
Submit this GW-1 within 30 days of well completion per the following'
i% stater Resources (DN','-R).
9.Total well depth below land surface: 8
40 24a. For All Wells: Original fort to Divrsi°ntir�7699-1617
r'mldup(e wells list all dryrhs i;ei/ferenl(ernmp(e-.i'a;lOti and-'' i00') —(ft.) Infom'ratiQn Processing
l.:nit.161.7 V15C.Raleigh.N
110.Static water level below top of casing: 24b. For Iniection Wells: Copy to MVR,Undercround injection Control t!Uf 1
/,rater level is move casut�,use
6 1/18 (in.) program.16366\14SC•Raleigh.NC 2?699-1636 v tt,the
f It.Borehole diameter. I�gird O en-Loo Geothermal Return Wells:Cop,
Air Rotary 24c.For Water Supp,
12,Well construction method: county er Tr health department of thee rnfnry.where inswlled
ai 1 i.t.auger.rotary.cable.direct pusL+.etc.l
— ;4d.For Water�Nells producin^over 100.000 GPD:Copy to D�VR,CCP(a .:
FOR WATER SUPPL\'WELLS ONLY: permit Program.161 I tilSC,Raleigh.NC_?699-161 I
Method of test:
Air Lift
L13a. eld(aPn') 1 1/2 LbsChloe. Tabs 4moDnt:sinfection type:
t` North Carolina 1)epamncnt of En6ronmeota!Quaht}:.I)rrs.on of\l'at r Resources �.
;r Form Gut-I