GW1-2023-01849_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD (GW-1), For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
1 14.WATER ZONES
Well Contractor Name t M
FROM TO DESCRirriON
•
3271-A _V0 ft- 322L X/7f
NC Well Contractor Certification Number
FEB 2,
15:OUTERCA ING for multi-'ca 'i& OR Lticable
B& K Well Drilling IncDIAMETERiedW
FROM TO MATERIAL
_ Fl—a-IMAP9
Company Name ft I ! in' I SDR-21 PVC
16.INNER CZING OR TUBING eother closed-loop)
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. tt. in.
Fw.ter Supply Well: .17'.SCREEN,'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3 WM ' ' L/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ; identi.1 Water Supply(single) ft. ft.
Industrial/Commercial [3Residential Water Supply(shared)
.18.GROUT
Irrigation FROM TO I MATERIAL EMPLACEME. E7rHOVA.A.MOVtE
Non-Water Supply Well: ft i ft.
:)Monitoring DRecovery
Injection Well:
DAquifer Recharge oGroundwatcr Rcmcdiation., f.L
19;SAND/GRAVEL PACK(if a' cable
Aquifer Storage and Recovery [3Salinity Barrier* FROM I TO 'I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. I ft.
Experimental :
Experimental Technology [3Subsidence Control ft. I ,- ft. I
Geothermal(Closed Loop) [3Tracer _20--DRILL G LOG(attirlit additional sheets If nJecessaryJ:-;;-,.:
Geothermal(Heating/Cooling Return) rJOther(explain under#'21 Remark.,) FROM--' f TO DESCRIFTION(color,hardness,sollfrock typ�_gritin sim em)
ft. ft.
4.Date Well(s)Completed:/-16 FWelI ID# ft. ft.
5a.Well Location., ft. ft
ft ft.
ft. ft
facility/Ownerl4arn Fa6ill'ty[1 al
Physical Address,City,and ft. ft.
ed, Wo?3
County Parcel Identification No.(PIN)
W
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I AA ad- 444f a7�, U-r// �/Cv
(if well field,one]at/long is sufficient)
22.Certification:
N W :2
a A ad
44rw
6.ls(are)the well(s)o Permanent or 13Temporary Si t of rtificwcll Con clot Liatc
V-signing is form, I hereb ccrtyi that rite well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ON-01" with 15A NC AC 67C.0100 or 1 M C 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and arplain lire nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section br 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIOP�S
9.Total well depth below land surface; 9p�_, i
For multiple wells list all depths if different(example-3@200'and 2@100D 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of cas. 40
Ywater level is above casing.use Ing: Division of Water Resources,Information Processing Unit,
1617 Mail Service' Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 118 (in.) 24b.For Injection Wells: In a I dd!ition 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.
Division of Water Resource1�,Underground Injection Control Program
,enter,
FOR WATER SUPPLY WELLS ONLY: 6 i
1636 Mail Service ,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 1 1
24c.For Water Supply&In! non wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfecdon e: Chlor Tabs 1 1/2 Lbs I I
typ
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 Revised 2-22-2016