GW1-2022-09876_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-1) For Lnternal Use only-:
1.Well Contractor Information:
Alfred iesl ;>. ,:... . ... ..:::::>:>::>:::::•> .;:::::<::;:::::> ...........:<:>>::
K ing Sr . .............,.......... ... .. . . .. .
FROM TO DESC:RIPTIO\
Well Contractor Name ft. ft. 0/-'
2670-A
NC!Nell Contractor Certification Number ..::� ?- /% l/
:;1�r�:UF1"FI�Z _�1�' Atml�:rs4ed�$etls:':E)$iit_t'QE•;R:'
B & K Well Drilling Inc FRONT TO DL-NIETER THICKNESS I MATERLAL
0 ft. 6 1/4 in' SDR-21 JPVC
Company Name
2.Well Construction Permit R: CJ f7 �a FRont r0 DIAS1E TER nItCKNE55 ntAz�Rt:u
Lirr all applicable well construction permits .c.U1C.Comrrv.State.VQa.'ancc:etc.)
3.Well Use(check well use): •
ft. ' f6 in_
Water Supply Welt: _... ... .
FFt0N1 I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agriculttua! ❑Municipal/Public it. it is
❑Geothermal(HeatineiCooling Supply) l<dential Water Supply(single) ft_ fL is
❑lndusmal/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>i00,000GPD FROM TO KILTERIAL EMPLACEMENT METHOD&:L1(OUNT
Non-Water Supply Well: 0 2 20 fL Bentonite Pour
❑Monitoring ❑Rcc:orcTY fr. ft-
Injection Welk
ft tr.
❑Aquifer Recharge ❑Groundwater Re-mediation
..:
»>.... < ...... : ']z3>: ,•'<>>.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
CAquiferTest ❑StormwaTerDrainage IT. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer ;Dki£LId9G; i 'gtiacii'aiFel*iieiiriE `.a .:'<>?%:`z:`:::<s:i3:»:::::<; ::::•::<:;:::':
FROM TO DESCRIPTION(color burdnem sontrock s- ' size.ercl
❑Geothermal(HeatinJCoolins Return)
qq❑Other(explain under=21 Remarks) ft o ft g�b �1&' �•�
4.Date Well(s)Completed- ��oc�Well ID# `� it. �© ft. r� q//J CJ /
5a.rWelll Location: L ) ft. ft /?/
Facility/Owner Name Facility M#(if applicable, ft. fL 1 •tL)�7 , y V .— �f
�j�i 1 1 O
ft. I ft. �.
Ph ical.Address,City.and Zry 0 fr- fr-
County Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if-cll field,one ladlono is sufeicnt) 939acC'unifiled
on:
N W -
6.Is(are)the well(s): !nPermanent or ❑Temporar Well Contactor Date
Brsigwng edit Jorm.l heml?t•rPrri �rirar rite�:rll(s1�rar(1VPlPJ<'an57raC'rPd in acmrdm+rP rrirh
7.Is this a repair to an existing well: E:Yes or 75.4 NCIC 02C.0200 hell Corrrtruction Standards and That a com•
!'this is a repair.fill aw kno++r well conrrrucri(m info,,r.arinn and explain the narure ol"rhe of this mend has Jx en provided to the+:r//owner.
repair rorder+21 remarks section or on the back of iNs fonu
23.Site diagram or additiunal well 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 i GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled. I /L_ _ 24.SUBMITTAL INSTRUCTTONS
9,Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For-multiple vel/s list all deprJts if(kffnvm(emt ple-3(at300'and 2 @100 j
10.Static water level below to of casino-40 24a. For all Wells: Original form to Division of Water Resources (Dw'R),
p a!f ureter level it ubore casing.rvd"+" (ft.) Information processing Unit'1617 MSC.Raleigh.ATC 27699-1617
11.Borehole diameter:6 1f8 ( ) 24b.For Iniection-Weils:Copy to DWR-Underground Injection Control(WC)
Program,1636 MSC,Raleigh,NC 27699-1636
(i.e..Well construction method:.auger,rotary.cable,direct push,etc.)Air Rota 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county enrironmental health department of the cotmry ullcre installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water WelLs producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Qg—J Method of test•Air Lift Permit Program,7611 MSC,Raleigh,TIC 27699-161 I
13b.Disinfection type: ChiOr. Tabs Amount: I2 LhS
Form GW-1 North Carolina Department of Enraonmcntal Quality-Division of Vdarcr Resources Revised 6-1-2019