GW1-2023-01777_Well Construction - GW1_20230223

i
WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: ki.;.
1.Well Contractor information:
Joseph Bailey P
14.WATER'ZONES a ,1'•::I:.::. ....:. ::: +;`'a;
Well Contractor Name FROM TO DESCRIPTION
3271-A t10ft. ft. G U
ft. ft.
NC Well Contractor Certification Number
15:OUPER CASING far multi-cased•wells
B .OR LINER'if Heable
'&K Well Drilling Inc FROM TO DIAMET!m_ Sl
HICKNESS MATERIAL
Company Name ft t ft 6t/2 iR-21 PVC
t+ �� 16..INNER-CASING'OR 7I)BING' eot&xmal closed=l ' +
2.Well Construction Permit#• off / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable-well construction permits(i.e.UIG County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN.
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS - MATERIAL
[3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single)
ft. ft. in.
Industrial/Commercial ®IResidential Water Supply(shared)
I8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U fr. O/ ft U
Monitoring Recovery
Injection Well:
q13Guifer Recharge fft. ft.A
roundwater Rcmcdiation
Aquifer Storage and Recov 19'SAND/GRAVELPACK da cable':
erY �SalinityBarrier FROM 70 MATERIAL EMPLACEMENTMETHOD
Aquifer Test 139tormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft ft.
Geothermal(Closed Loop) 13Tracer 20.DRU LLNG LOG attach addid6iW.iheets if
Geothermal(Heatin Coolin Return) Other(ex lain under#21 Remarks) FROM ro DESCRIPTION(color,hardness,soil/rock e. rain size;etc.)
ft. fr. .16�
4.Date Well(s)Completed: Well 1D# G10 'ft. o ft. C
Sa.Well Location: O ft. ft.
�andy -arver f l ShIY�C'1>�t//I ft fL / h�ll Syi, t �
Facility/Owner Name Facility ID#(ifapplicable) ft.
240 ZaAri 475-h,Dr.
Physical Address,City,avnd Zip ft ft. d ;
County Parcel Identification No.(PIN) FEBLUJ
I'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees ^ M: ^,.iF 1 Unit
(ifwcll field,one]at/long is sufficient) ! ^�;,•�••-
22.Cert' cation: �vr (,1Q.1JG
' ":J
1
N
6.Is(are)the well(s)OPermanent or Temporary Si ature of crtifi dAoannacto Date
Yes or Yp
By signing this Arm.I herehs certfi lhal the well(s)was(were)constructed in accordance
7,is this a repair to an existing well: [3 with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Nell Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature nflhe copy tfthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. I
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 pagd,`to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: u
1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !'
For multiple wells list all depths ifdifferent(esample-3�a120 'and 1 a 100D (ft) 24a. For All Wells: Submit this;form within 30 days of completion of well
construction to the following:
If
f Static water level below top of casing:40 (ft) Division of Water ResouIrces,Information Processing Unit,
water level is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ '
(1D') 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
y / 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: //// `1 � 24c.For Water Supply&Iniecti In Wells: In addition to sending the form to
Chlor Tabs t 112 Les the address(es) above, also submii dne copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. I ;
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016