GW1-2023-01862_Well Construction - GW1_20230222

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WELL CONSTRUCTION RECORD(GW 1) 1"""''`='
For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
a:14R'ATER'ZONES'. ` lt:..i:i :''Well Contractor Name T t^, o. 'f FROM TO DESCRIPTION
3271-A 24s�Ze_
NC Well.Contractor Certification Number FEB
p 2i ^0 23 ft. ft 1
r L D 2 L -15:OUTER:CASING: OR=LEUX d"`"'B&K Well Drilling Inc FROM TO DIAMETER THICKNESS fiMATERIA. Y
___:_
Company Name ifls�irt+s .� - :° 0 ft ft. 61/2' in. SDR-21 PVC
J�eQlS.�ly 16.'.WNER:CASMG:ORTUBINGt eatilermaldilsed:I' :...:-': ?._•';'r' ,:"^-`'<'.;:;:;a;._;,.
2.Well Construction Permit#:- � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ii.e.UIC,County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
[Geothermal
Supply We11: 7.,CDllural TO DIAMETER SLOTSIZE THICKNESS MATERIAL
�Municipal/Public ft.(Heating/Cooling Supply) esidential Water Supply(single) fr, in.
striaUCommercial Residential Water Supply(shared)
18:GROIIT
atrrigton FROM TO MATERIAL EMP CEMENT M THOD&AMOUNT
Non-Water Supply Well: ft. ft. ,
Monitoring Recovery fc ft
Injection Well:
Aquifer Recharge Groundwater Rcmediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19:SANDIGRAYEI PACK tfa cable>:n .; =.._..•_::; a. „,;;,,.?;
FROM TO MATERIAL EMPLA
Aquifer Test oStormwater Drainage ft. ft CEMENT METHOD
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer
:2o.�nR1Llnv0, t3G:a[tachaiidttioua[sheetsit necessar
r:^r ,.'::;;,•,;-;,z �i
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRIPTION(color hardness,soi0rvck e. In shre;eta.)
�� ft. fr.
4.Date Well(s)Completed: Well ID# �' ft. ft' ✓'dL,/)'f �_ �
5a.Well Location: ft. O ft.
ft.
�,�j
Faoitihtq/Owner{N/a� nme�� Facility ID#(if applicable) ft• fJ ft. B
1l 'Wl�(i(�i�� �/ �i/r ft. ft. /( e
Phys,ca Addr s,Clty,and Zip ft. ft.CQ. fa�ytJ QV`-Cr�q 21.REMARKS:
ounh' Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
N W
6.Is(are)the well(s)oPermanent or 13Temporary 1with
aturc ti all C ctor I Date
-
signign g this form.1 he y certify ihat the well(s)was(were)cunstr-ucted in accordance
7.Is this a repair to an existing well: Yes or PfQp ISA NCAC 01G.01 or 15.4 NCAC,02C.0200 Well Construction Standards and that a
Ijthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
S.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:
�,,,r I SUBMITTAL INSTRUCTIONS
9. multi well depth below land surface: a5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a!1 depths ifdifferent(example-3@200'and 2@1001
construction to the following: I
10.Static water level below top of casing:40 ft. '
Ifwater level is above casing,use"+•• ( ) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In additip n to sending the form to the address in 24a
12.Well construction method: Air Rotary above,also submit one copy of thisiform within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ,
1636 Mail Service Center,Raleigh,NC 27699-1636
� ) /.� r 13a.Yield m Method of test: r% ' 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2 Lbs 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 ResourceRevised 2-22-2016