GW1-2022-00181_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 1a:WATER'ZONES.
Well Contractor Name FROM TO DESCRIPTION
Oft. ft. UK �e
3271-A o G�j
�ft. 'e-
NC Well Contractor Certification Number `nn' ::15'OUTER,CASING fo[multi casediwells;OR LINER;if& Ilcatile
B& K Well Drilling Inc DEC 1 21,2Z FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft, ft. 6 112 in' SDR-21 PVC
lfliCiifiattDl 7r^•:•r ^ Ur!!
nrks'�-:�� 76;WNERCASINGORTUBING 'eotlierinatdosed-l00P) __.,
v u e 01 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ;17SSCREEN vn s.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public fr. ft. in.
Geothermal(Heating/Cooling Supply) M<gidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18,G ROUT
, s>
Im ation FROM I TO MATERIAL EMPLACEMENT MTHOD&AMOUNT
Non-Water Supply Well: ft. ft. , onr'�"ie d a-
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwatcr Remediation
Aquifer Storage and Recovery gg��Salmi Barrier 19l'SANDIGRAYELPACK rfa licsble
@_,p ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [i Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer 20.'DRILLING liOG'attach sddi600al sheets'if uecessii' t.x,�s�
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM 1'O DESCRIPTION(color,hardness,soillrock type.grain sizei etc.)
10 2 E _7
4.Date Well(s)Completed: Well ID# /L�� ft. ft. miil l Oi
5a.Well Location: ft. ft. fat J! ty
Facility/Owner Name Facility ID#(if aapplicabl ft. lift' Q &L/
19 �SPnnUS�i'G4/ G 7�°, �T�s/%I�f�,luz 77 ft. - br
Physical Address,Ciit/t,nAand Zip ft. ft.
21
.REMARKS:'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certification:
N W -.11tA49r j .
St t re of crtlfi d Well C n or Date!
6.Is(are)�fhe 1ve11(s)�Permanent or Temporary
Z;'Ii
gning Thisform,I hereb•c rtify that-the well(s)uas(were)consnvcted in accordance
7.Is this a repair to an existing well: ®Yes or K3`No w15A NCAC 02C.0100 o A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of file copy of this record has been provided 10 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: �UC� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'mid 2@100') construction t0 the following:
10.Static water level below top of casing:40 (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: 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 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016