GW1-2023-01778_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD (GW I) I?nnt.Fo[m`.
For Internal Use Only: �
1.Well Contractor Information:
Joseph Bailey
14.WATERZONES
Well Contractor Name FROM TO DESCRIFFI—O
3271-A fr. ft. .1 1 —
(116yy Zoe
t 0 ft. �y7 ft. I
NC Well Contactor Certification Number 7 r �j
B &K Well Drilling Inc 15..OUPERCASING for multi ed:wells OR LINER ifa Ikable >,s;%:"=•, :,,
FROM
tt� TO DIAM1fETER THICKNESS MATERIAL
Company Name L/ [L f 6 1/2 I; 1°' SDR-21 PVC
O^ "1C.W NER CAS G OR 7 UBING. eoffierntal closed-lau :'
2.Well Construction Permit#: L U (/ J FROM TO DIAMETER THICKNESS MATERIAL f
List al/applicable well construction permits(i.e.UIC.Comity.State.Variance,etc.) ft. ft. in.
I,
3.Well Use(check well use): fr. ft. in.
[1n7Y
Supply Well: IO:SEREEN... ::
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
[3Municipal/Public
hermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft.
strial/Commercial Residential Water Supply(shared) ;
Irrigation FROM TO MATERIAL EM1IPLACEMENTMETHOD&AMOUNT
ater Supply Well: ft. fL
toring Recovery [t. ft. 6
n Well:
fer Recharge Groundwater Remediation 1L ft.
fer Stooge and Recove PaCiC d a cabte<ry Salinity Barrier FROM TOfer Test [2Stormwater Drainage ft.rimental Technology Subsidence Control ft. ft.
ermal(Closed Loop) Tracer
G LOG attachaddWanMt heets ifneermal(Heatin Coolin Return) Other(ex lain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soillrock tv`e.g rain size,etc)
ft. fr.
4.Date Well(s)Completed: Well ID# 1d`T L 7/�/ ft. ft. a
5a.Well Location: ` ft. )ft.
�l�Khl1I o ft. ft.
L�d� rG✓ G
Facility/Owner Name Facility ID;#(ifapplicable) U 1t- (` Wit. �
Physical Address,City,and Zip ft_
G �r/L✓/3 ­21.REMARKS -
County
Parcel Idcntifrcation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Ce cation: 2023
N
6.Is(are)the well(s)OPermanent or' Temporary i aturc of citified Well Co tac r Dat
v signing this form, 1 here&c t fti that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well �YeS or �No irh ISd NCAC 02C.0100 or SA.NCAG O2C.0200 We!(Construction Standards and that a
llthis is a repair,fill out known well construction information and explain the nature offhe copy ofthis record has been provided to the well owner.
repair under ff2l remarks section or on the back of this form.
23.Site diagram or additional wellidetails:
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also ai ach additional pages if necessary.
drilled:
�O SUBMITTAL
✓•2 BMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
1.
For multiple wells list all depths ijdifferent(example-3(a�200'and 2@IO())
10.Static water level below top of casing:40 construction to the following:
Ijwater level is above casing,use'•." (ft.) Division of Water Resourf es,Information Processing Unit,
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
12.Well construction method: Air Rotary above, also submit one copy of this mt within 30 days of.completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Celitei,Raleigh,NC 27699-1636
13a.Yield m !l I
(gP ) U Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor abs 11/2Lbs the address(es) above, also submit gone 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 2016
Revised 2-22-