GW1-2023-01854_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Baile �
,. t �F_s- i.�q�^. , u .:14:VYATER ZONES(.
Well Contractor Name TO 1 DESCRIFF ON
3271-A FEB 2 2 2023 G� ft. I-
NC ft.
I
NC Well Contractor Certification Number 1
15:0UTER`.EASING:foriuulti=caved'wetls OREINER:ifa."llralile ;_-;::.•;�::";?::5'
B&K Well Drilling Inc tb?p^ItJ T�Klu
DIAMETER ' THICKNESS MATERIAL
Company Name ft. 6112 ;' in• SDR-21 PVC
/1 !' FROMGY3R:FIIBING: 2otheeatal`closed=I
2.Well Construction Permit#: � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits('.e.UIC, otmty.State.Variance.etc.) ft. ft.
3.Well Use(check well use): ft. ft. i' in.
Water Supply Well: 17:.SQtEEN '.:: >
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �MunicipaUPublic ft. fr. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft fr. in. .
Industrial/Commercial 13Residential Water Supply(shared)
Irri anon 1&.GROUT::',;:c:r,::?s :=_r' -:::. :;?::':i:,;.a:- ,;c •.::4, :.:;,>:";:: ::i<,;:::::::':.;:.
,FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: it tt r
Monitoring []RecoveryToq� 07/r
Injection Well: v
Aquifer Recharge [30roundwater Rcmediation ft. ft.
Aquifer Storage and Recovery [)SalinityBarrier 19:SANDJGRAS'EL PtiQC rfa cattle :;l:.
FROM TO MATERIAL' EMPLACEMENT METHOD
Aquifer Test E3Storinwater Drainage
Experimental Technology Subsidence Control ft fr.
Geothermal(Closed Loop) Tracer :20 DRIiLTNGLCIG at cfi�additioualiheetsa£
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRI ION(color,hardness,soil/rock a in strA etc.)
ft. ft. � i �.'
4.Date Well(s)Completed: I Well ID# fr fr• Q n fit•
5a.Well Locatio r,/// _,�/// //(� f //�����(
P �• efs �Ah.1- R.40,c YIfw 1/(mil f� . eT/
acility/0t rNammee Facility ID#(ifapplicable)
�� �SL i\��Ii �C. f Y✓N 1^"40/ 1V 4k ft. ft. i
Physical Address,Cit,and Zip — ft ft.
21.
County Parcel Identificati n No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certifica'on: i
N M, I �j
6.Is(are)the weU(s)oPermanent or Temporary Si of Cc cd W 1 ctor ;: Date
8 signing ih' jorm,!hereby cent tha ie wel!(sJ was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or o ith 15 NCAC 02C.0100 or 15.4 N 02C.0200 Well Construction Standards and that a
V"this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to theme!!owner.
repair under#21 remarks section or on the back of thisform. 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 page to,provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i-
I SUBMITTAL INSTRUCTIONS
l
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 00'and 2@1001 construction to the following:
10.Static water level below top of casin 40
g: (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 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 nit 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,
1636 Mail Service Centl r,l Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test:A li-rl-, 24c.For Water SuDDiv&Iniection Wells: In addition to sending the form to
Chlor Tabs t 1/z Lbs the address(es) above, also submit ofiel 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 I Revised 2-22-2016