GW1-2023-01853_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
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1.Well Contractor Information:
Joseph Bailey
141lWATERZOIVES. ;':;:-.?:'4;'1 '-;;:'°%.
Well Contractor Name "RVMTODESCRIPTION
3271-A ' : r fy'�"- �' ft. �ft
f I
NC Well Contractor Certification Number {� � ����
FEBt 15:OUTER CASING for.'mu1L ned w OR-LINER'if a licatile :=
B&K Well Drilling Inc FROM TO DIAMETER I THICKNESS MATERIAL
Company Name " "tv""`cap 1 : r.:_:,? Lri, ft ft 61/2 1° SOR-21 PVC
to C+. •�.:
��!Y� 9���°/ ]( •�16 NNER CASING:OR:TUBING eorliernta!elased-lao" -_:z: ;i'::< '•
2.Well Construction Permit#: /T�✓ w 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. j in.
3.Well Use(check well use): fc. ft. in.
ater Supply Well.
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural QgMunicipal/ blic ft. fr. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
Industrial/Commercial Residential Water Supply(shared)
s18;GROUTIrrigation :;zY.: �:; ..' .::. ....:...:.:........_....,.,::::,,<x;?'�:,:ys�_::::;s,...:...:::..:.•,
FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery
Injection Well: ft. ft. G Oky
ft
Aquifer Recharge [3Groundwatcr Remediation ft.
19 SAND/GRAVEL=IrAt[C d,a..,. &file ::_, �:','. ::,.. ,.....•:... . ,. ..
Fw—
Aquifer Storage and Recovery Salini Barrier y -:. '^.-s•> 1:.>-:a"„c:•
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [39torinwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:D RIfiLING-L0G at6khiddI&iliIih&t3!f
TO D
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM ' ESCRIPTION(color•hardness safl/ock`•`�grain skM etc.) .E.
ft ft.
V � 1
4.Date Well(s)Completed: Well ID# ft fr.
B
5a.Well Location: ft. ft.
[ 1je Kil u� �a �1'�if ft 1p ft
Facili /Owner Name Facili ID#(if applicable) ft. ft. C a f LrX
6G
��L� L ] �+ d ft 3 o ft. �n r?1G
/ ,�i It✓i►{'I C � c,u�1'�-JG � IVC o�D�� • � I D
yslcal Address,City,and Zip ft. ft.
46 ��- 1033�3 21.REMnRIcs : . -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)OPermanent or ®ITemporary uts of ertificd c I Con for Datc 7/
Z"i9l,
t is form, 1 herefiv certi that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ED� 5A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
!'this is a repair,fill our known well construction information and explain the nature of the copy ofthis 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
f SUBMITTAL INSTRUCTIONS
I,
9.Total well depth below land surface: Q (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i#different(examp e- 200'and 2@100�
construction to the following:
40
10.Static water level below top of casing: (ft.) 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 Injection 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 foml within 30 days of completion of well
g
(i.e.auger,rotary,cable,direct push,eta construction to the following:b' I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I '
13a.Yield(gpm) Method of test: 4, / 24c.For Water Supply&luiection iWells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above, also submit onel 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016