GW1-2022-09773_Well Construction - GW1_20221027

- I
WELL CONSTRUCTION RECORD LGW-1) For Internal use Only.
1.Well Contractor Information:
Alfred K i-esl mSr
9 S
FROM TO DE.%CRrMO.1 w
Well Contractor Name ft. ©
2670-A 9
NC Well Contractor Certification Number Q3 (L 0"' ft. FV S
`.BE1ZFi1i4_i BCmt agidSeRc:: i tQ£3Y.
B & K Well Drilling Inc FROM TO DIA-METER I THICKNESS MATERL-iL
0 ft- I q ft. 6 1/4 SDR-21 PVC
Company Name
y q
2.Well Construction Permit R:/�' �Q ! 1 7-6 txont TO UTA�1E rER THICKNESS MATERIAL
LLrr all applicably well cwumlcGwt permits .a.UIC.Gorvrrv.State.Variance,etc.) (t• ; fL
in.
3.Well Use(check well use): ft. ft. is
..2_ E&1!F:ii�i:?�it::ii:.?2>::`:`:.::'�i .:.i:':}':.;::::i..3�`�:i Ci:':f:i3 :•:.:�i 0� 3:'•<:i<:i>.>':>.� i
Water Supply Well: . ._ ... ...
FROM TO DIAMETER SLOTSIZE THIC.KNFSS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft_ in.
❑Gcother(rial(HeatmgiCooling Supply) 8lzestdential Wattx Suppiv(single) ft. fL is
❑Indust iaUCommercial ❑Residential Water Supply(Shared)
.........
. ........ YT AiU1
❑hrigation ❑Wells>100,000GPD FROM To KILTERULL EMPLACEME METHOD&.11O
Nun-Water Supply Well: 0 (� 20 fL Bentonite Pour
❑Monitoring ❑RCCOVcry
Injection Well
ft. ft_
❑Aquifer Recharge ❑Groundwater Remediation :. ::.....:.,:::.,,:.::.>:.::: :.:::::.:•:::::.;;:z>:::.:-:: ;:•::::•..::.::;-:
::}4:i5:$1�`t3i�fC3Y�fi:L'.3fd�t'� le}•::::;_:>::::::••:::i:;'c::::<::<::::>::�::::::::::.;:%:<:•:•::•k.;;.::::?.:
❑Aquifer Storage and Recovery []Salinity Barrier FROM To ldAT£RIAL I EMPLACEMENT METHOD
❑AquiferTect ❑Stormw'aterDraiDage ft. ft_
❑Experimental Technology. ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer F;RILiNG;£o 'atlsck'a&tieorirFs3aers3#'eceaiar
❑Geothermal(HeatinJCooling Retum) ❑Other(explain under#21 Remarks) FRQAl TO DESCRIPTION(color barenessw took ?rave nize-
erU
fc. 1(5 ft. 9
T
4.Date Well(s)Completbd= Z'2-Well ID# ft. ft. v
Sa_W 11 Location: Sft. fL
ft fL t (� r
Fft. fL
Lac'QylOnrnrr/Narnr ! ,Facility m#(if applicable;
Physical Address City.arA Zip / ft- fr °' -i l� 0 q-e a
f'� :':i2i�TLEi4�t�4 County Parcel Identification No.(P1N)
Sb.Latitude and longitude in degreesJminatesiseconds or decimal degrees:
(ifwcll field,one latilono is suffieicntl 22.Certificatiun: v0iG
W. 1 -
6.is(are)the well(s): nPermanent or ❑Temporary ip t ofCertined WefI Conaactor Date
Br sigaing ih r)wwn.1 herehn•rerrijr tear the+:r sl+nos(rvereJ ronstrutved in accordanve+rith
7.is this a repair to an existing well: ❑Yes or -!INo 15.4.-VCIC O'C.0100 or 75.4 A'CAC 02C,0200 JteComvDwcxon Standards and that a cant
1(rhhv is a repair.fill our knon,p well constnurtion info,zraiinn and erplatn the namrr-of the o(this record has brrn provided to the v.rhl or .er.
repair rorder t21 reznar kt section or on the back o(rhrr form.
' 23_Site diagram or additional 1veII details:
8.For Geoprobe/DPI or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction_only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:
7 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_S")�5 (ft)
For multiple units list aft depilu if tfi ferenr(trample-3(r1200'arrtt @V 00) Submit this GW-1 within 30 days of well completion per the following:
10_Static water level below top ofming:40 24a. For All Wells: Original form to Division of Water Resources (DWR),
!(muter level&ubor er casing,twe-+•- (R.) Information Processing Unit,1617 MSC,Ralei--h.NC 27699-1617
11.Borehole diameter-_6 1/8 (in) 24b.For Injection Wells:Copy to DWR-Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Wel
(i.e.auger,12-auge tonstrnctir,rOfary.Cable., method:Air Rotary Program,
For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
direct push,etc.) county environmental health department ofthe county inhere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gp m) /-.I— Method of test: mt Air Lift Peit Pro--ram.1611 MSC,Raleigh,NC 27699-1611
13b_Disinfection type: Chlor, Tabs Amount- 1 1/2 Lbs
Form GW-1 Norrh Carolina Department of En.iroacrenral Quality-Division of Warcr Resources Revised 6-6-201 K