GW1-2022-00237_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey gs c�`a p 4 �A4!WATERZONES•r_ ,n
Well Contractor Name ° 1— — FROM TO I DESCRI TION
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3271-A DEC 1 G 2022 5-ft-ft.
c `�� ft.ft. 0.1 1�4�� � LrtIYL
NC Well Contractor Certification Number 15:OUTER,CASING`foe=multi casedivells OR,LINER'if'a lie
Iflivrile ;tC1 ?r.C? rvt'31r ul� able
B &K Well Drilling Inc �oQ1J.� FROM TO DIAMETER THICKNESS MATERIAL
ft. ' ft. 61/2 in• SDR 21 PVC
Company Name
1�n I&INNERCASINCOR'TUBING" otherrnalclosed-loo ; �' .t.,,?„ �:�ua
2.Well Construction Permit#: (^� /1V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pe, ats(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: -17.SCREEN, �. '" ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [LJ3MUpnja4ra17Public ft. ft. in.
Geothermal(Heating/Cooling Supply) lairesidential Water Supply(single) ft. ft, in.
Industrial/Commercial Residential Water Supply(shared) --
Ini ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R. ft. '
Monitoring EIRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19r'SAND/GRAVEL PACK
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft, ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 2os1DIiIILINGIsOG aunchadditfonalsfieetstfnecessar
FROM TO DESCRI TION(color,hardness,soiUrock e, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. it. Red -� J#
4.Date Well(s)Completed: / o� Well ID# ft. ft. d1
ft' ft. �n! f0w17
Sa/t.�Well
�Location:hgo�f �� �f y� /�/,�Q
Facility/Owner Name Facility ID#(if applicable) ft. ft. e-
a P/
>r- �a b ft• vlo-
P ysical Address,City,and/Z'ipka
Q ft.
�G U,S G Q ,.2E REMARKS-
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one]at/long is sufficient) 22.Certi ation•
N W
/,7a
6.Is(are)the well(s) Permanent or OTemporary Sig Lire of rti is ContVitha�,l
Date
B signing his form,/hereby cc the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ` owith ISA NCAC 02C.0100 a I 01C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
X i
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'a„/2@100� construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service(Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection 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&lniection Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs
the address(es) above, also submit one copy of this form within 30 days of
Amount: 1 1/z�bs 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 Watcr Resources I Revised 2-22-2016