GW1-2023-01851_Well Construction - GW1_20230222

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor information: i
Joseph Bailey
14 WATERZOh`E5:_.':':-s:,.:.:;•: b':I'..•: ::
Well Contractor Name _ FROM TO DESCRI ION
3271-A
NC Well Contractor Certification Number rt. ft.
_p nq
FtD v 2l'L� 15.OUTER-CASPiG foririniti=casediwells)UREllYER'ifa 13raUle; ;< ;r'r •:;;:•:!t:.':;;
B &K Well Drilling Inc L FROM TO DIAMETER ! THICKNESS I MATERIAL
Company Name STiiC•i'Ft;Fb�:^1 i''rL�ry^.e+; �Llftil ® rL i_.;'Cy ft 61/2 1D SDR•21 PVC
(J/��D� r`I'6:'EMWER+C11S1NGXDR TUBING' tSirniai elosed=2"' %r>Y__;`i''3 ,!%:."•'
2.Well Construction Permit#: j�(�r/ (/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permtts(f.e.UIG County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ffi I in.
Water Supply Well: IT SCREEN
FROM TO I DIAMETER I SLOT SIZE THICKNESS I MATERIAL
Agricultural ![PMunici Public ft. It, in.
Geothermal(Heating/Cooling Supply) QRSidential Water Supply(single) ft R in.
Iodustrial/Commercial Residential Wate
r SuPP1Y(shared) •V-48.GROUT
,...
71
Irrigation
FROM TO MATERIAL Ebi LACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt fL ni yr �!1
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwatcr Remediation
Aquifer Storage and Recovery [r3�Salini Barrier FROM D/GRAYEGPAt3I MA .:MPLACEM T'ME OD
Psi' ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage f[. ft I'
i
Experimental Technology Subsidence Control ft. ft. I
Geothermal(Closed Loop) Tracer 211i:DRILLINGLOGatfacliddltioiiat3heetsitiie
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness.solFcock•..type,• grain sire;eta) ~~
nn / D ft ►o ft. ,1
4.Date Well(s)Completed: ' 0� �t� Well ID# _O L) .10 ft. oft• /yam// 5 Oi
Sa.Well Location-
rt. , v ft
AA A ft (` ft.
'Facili /Owner Name Facili [D#(if applicable) ft. ft. r�_ r /Q, � 1'�a
r6�3 R,-rh/C ,77411a� i(// 9 ft ft. // roTGRae
Physical Address,City,and Zip ft. ft.
A.u.n,y
Ioa b z1..RvMaxxs: :>::; _ - .�:r Parcel Identification No.(PIN) I.S4. C>`/�/!/�Ita l t, aJ/e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n?Qe�t C !c ok ar—(✓C! ea !a
(if well field,one lat(long is sufficient) 22.Certifi do
i�
N W r1
/ A�3XZZ
6.Is(are)the well(s)OPermanent or Temporary Si ure CcrtZ. -O
l Co ctor Date LZ IF
y signing this form., v certif that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13
Yes orj�No with 15A NCAC 01 or 15.4 NCAC 62C.0200 Well Construction Standards and that a
Ifthis is a repair,fdl out known well construction information and explain the nature ofthe 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-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled:
ol�/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_4 —(ft-)- - 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200 and 2@1001 construction to the following:
10.Static water level below to of casing:40
p g: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Cenier,�Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (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
(i.e.auger,rotary,cable,direct push,etc.) g• !
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,"Raleigh,NC 27699-1636
13a.Yield(gpm) D Method of test: 24c.For Water Supply&lniection Wells: In addition to sending the form to
the address(es) above, also submit duel copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/z tbs completion of well construction to thl county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016