GW1-2022-00224_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14 WATER ZONES:-'_ „oy _
Well Contractor Name FROM TO DESCRIPTION
3271-Aj et. ft. ��iG O�G
G fc. ft. d!Il// / /.Or.4. ge?
NC Well Contractor Certification Number 15.OUTER' 'A SING foe multi-cased'vells OR LINER it a livable =
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
p ft. ft. 61/2 in.
SDR-21 PVC
Company Name
16.INNER CASING OR TUBING eothernlat closed-loo -.
2.Well Construction Permit#: VG! -0— FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pef»sifs(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1,7.,SCREEN`"':
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in..
Geothermal(Heating/Cooling Supply) JEResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) g.GROUT
h'ri ation FROM TO MATERIAL EMPLACEMENT I%IETH D&AMOU T
Non-Water Supply Well:
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK if a licible_
qry tY FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft, ft.
Experimental Technology Subsidence Control tt. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additi-hat sheets if 66eessa
Geothermal(Heatin Cooling Return) Other(explain under#21 Remarks) FnoM ro DE RIPT N(color Hardness,soil/rock typ e, rain size,etc.
ft. ft. C'O1
4.Date Well(s)Completed: V d t� Well ID# /� D ft, ft. rt7i-111 '5-01
/'1 ft.
SaWell Location: l _ ft. V
�� 11/ rt. rt. C `/,1&47 .?,2 61.
Facility/OwnerName Facility ID#(if applicable) Jft.
�n Ina ry 7e_ OG�
Physical Address,City,and Zip ft. ft.
2L.REMARKS.
County Parcel Identification No.(PIN) i-1 I I` 1!2_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) lSl`1-- D� x v
22.Cert`Icati n: FIVI`4Q,'
N W /�
6.Is(are)the well(s) Permanent or Temporary ure f Cc i s ell Cont for Date
— ryuh
gning this form,I her•by ertify that'the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or EINO 15A NCAC 02C.0100 15A NCAC 02C.0200 lVell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn. '
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: t��U (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection 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
_R
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection1Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs 1 1/2 Lbs
13b.Disinfection type: Amount: completion of well construction to t ie county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20]6