GW1-2022-00239_Well Construction - GW1_20221216

Print Form ;r
WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
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Joseph Baileya:'wATER�zoNEs _. . s .
Well Contractor Name FROM 1'0 DESCRIPTION
/Spft. , ft. I
3271-A
ft. ft.
NC Well Contractor Certification Number u'AS OUTER CASING;for multi-eased wells.OR=LINER if a livable
B& K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. S8' ft. 1 61/2 in, SDR-21 PVC
06ANNER CASING OR TUBING(geothermal cleied400"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
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: 17.`SCREEN/:�
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
m Industrial/Comercial [JResidential Water Supply(shared) ig;,CROUT ';`°.t° - "
ation FROM TO MATERIAL T EMPLACEMENT METHOD&AMOUNTS
Non-Water Supply Well: G ft. R 0 ft. -7e— Vr
Monitoring Recovery ft. ft.
Injection Well:
ft. ft. .
Aquifer RechargeGroundwater Remediation
197SAND/GRAi?EL PACK rf a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology E39ubsidence Control ft. ft.
Geothermal-(Closed Loop) OTracer 2R DRILLING LOG(attach add[flohal�sheets If oecessary:
Geothermal(Heating/Cooling Return) rl Other(explain under#21 Remarks) FROM TO DESCRI l'ION(color,hardness,soillrock type,grain size,etc.)
i� 0 ft. <a- ft. 1?eJ';0iq
4.Date Well(s)Completed: �0/ Ol Well ID# ft' a ft, 1 r6vq 5d
Sa./Well
�Location: / NX �ft. ft. ' f
ft. 105"ft' 5, /r L
Facility/Ow er Name Facility ID#(if applicable) ft. gift• n C O
bA 42 hna 1 fAl Z. ft. ) ft. --
P yy1ssiiccay l Address,City,and Zip ft. ft Ic V e y �y a
!�{ 5�� yt'3 _21.`REMARK3tr=
n
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Pr 2r 3f ro Ra. t Ina
(if well field,one lat/long is sufficient) r.1.1frL�
22.Certification: r-,
N W _z..4 A X,/
6.Is(are)the well(s) Permanent or OTemporary Sign re of C ,fie We ontra ror Dat
B signing this form,I hereby c of that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or No wuh ISA NCAC 02C.0100 or IS CAC 02C.0200 Bell Construction Standards and that a
Ifthis 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
9.Total well depth below land surface: 46or (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@/00') construction to the following: 1
10.Static water level below top of casing:40 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) ',`/y 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
Chlor Tabs 1 1/2 Lbs 1 1
13b.Disinfection type: Amount: completion of well construction to ithe 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
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