GW1-2022-00111_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
P Y lCl� -WATER ZONES .,k,
r'� FROM '1'0 V DESCRIPTION
Well Contractor Name "" ' m ft.
3271-A DEC 1 t� .2Q22 rt. It. I �
NC Well Contractor Certification Number tc ]STOUTER CASING for multi cased vclis`OR LINER iI `Itcabli �..,,r=•.,'n
B&K Well Drilling Inc lnfbns� cn Pm.,,;Dov.,lv^J Unj FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' 61/2 i SDR-21 PVC
����v����0 -16r-INNER CASING OR'TUBING` iSbthermai closed-loo ' r"-�_•_ i `-
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It. rt. in.
3.Well Use(check well use): ft. tt. rn.
Water Supply Well: ail.=SCREEN'_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DM ' ' al/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) &sidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) ;
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. it.
upai
Monitoring ORecovery ft. ft.
Injection Well:
Aquifer Recharge OGroundwater Remediation
.'19;'SAND/GRAY,E>s-PACK if a'"licable '"
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer �20:DRILI:ING'I OG attacli�addifionslsheetsaf
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DFSCRIPTION(color,hardness,soil/rock type,grain size,etc.
ft. ft. im.'5101
/
4.Date Well(s)Completed:,l0�/� Well ID#aT—nQ' ft. ft. rl t
5a.Well Location: Oft, ft. /G Sin j
yd ram,/ s lin�I ut�il✓J ("q kP � f ft. ft.
/1 '
Facility/Owner an -- Facility ID#(ifapplicable) ft. /6 ft. el ® �_ - I
V rt.
Physical AdWess,City, Zip t. ft.,15
Lo6d /`ate
County ( - Parcel Identification No.(PIN) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certif ation-
N W in 1
. A.
6.Is(are)the well(s)o Permanent or Temporary ' atic ofri.,form,
rtificd Co or
Dat
signing t I hereby cer7� hat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or EjAI� ith 15A NCAC 02C.0100 or 15A AC 02C.0100{Nell Construction Standards and that a
/"this is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details-
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2 rr 100') Construction to the following:
10.Static water level below to of casin 40
p g: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �Method of test: -rt r 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016