GW1-2023-01864_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
Well Contractor Name FROM '.1.0 TDESCRIPTION
3271-A ft' ft-
NC Well Contractor Certification Numbersql� I ✓l//�
15.OUTER.CASING for malticased'.iveHs.ORLINER ifa licable
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
t
Company Name ft i ft. 61/2 J in• SDR-21 PVC
16.INNER CASIN(�G OR TUBING eottiermai'dosed-ion '
2.Well Construction Permit# 'G 6� p l ,�/,i " 5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CunNv.State. Variance,etc.)- ft. ft. in.
3.Well Use(check well use): FEBr 2 2 2023 ft. ft. in.
Water Supply Well: r, �. :17:.SCREEN•'
FROM TO DIAMETER SLOT SIZE THICKNESSS MATERIAL
Agricultural �MuniiSTt (ibJCo,; ft. ft. in.
Geothermal(Heating/cooling Supply) Residential Water Supply(single) ft ft in.
IndusttiaVCommercial Residential Water Supply(shared) -
18.GROUT :..: .
hTi ation FROM TO MATERIAL EM L4CEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. go,
ft �
Monitoring Recovery fr. ft.
Injection Well:
Aquifer Recharge ft. ft
9 g �Groundwatcr Rcmcdiation
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK d a 'cable ' ".
9ry Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft• ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTmcer 20.DRILLING LOG attach addltitinal sheets if ire _
Geothermal(Heating6pooling Return) n Other(explain under#21 Remarks) FROM TO DE.SCRIPr10N(mior,hardness,soiltruck e,.grains ze eta)
ft fz
4.Date Well(s)Completed: Well ID# ft fr. i
s�� si,
5a.Well Location: d ft. G ft /�W
eS�_ III Algrri (.k�A� ft ft �?ll✓� �4
Facility//C61icrName Facility ID/#(ifapplicabic) ft• ft /
ack
Physical Add ss;qjty,and Zip J ft. ft.
l�_'f_SFCI��! �� (O 21..REM4RICS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi 'on:
N W ^ t
6.Is(are)the well(s)oPermanent or Temporary tore ofC tfic onttactor Da
y signing r is form, I herehc c•ertiJ t i the w•ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or 1Tvo itlt I5A IV
02C.0100 or 15.4 AC 02C.0200 Well Construction Standards and that a
Ijthis is a repair,fill out known well construction information and explain the nature gf1he copy ofthis record has been provid 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS .
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 ijdijjet ent(example-3@200'and 2 a 100� construction to the following:
10.Static water level below top of casing:40 ft.
( ) Division of Water Resources,Information Processing Unit,
Ijwaterleve!is above easing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (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,form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources, nderground Injection Control.Program,
FOR WATER SUPPLY WELL ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m
(gp ) Method of test:A, 24c.For Water SuoDly&Iniection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above, also submit lone 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. f
Form GW-I, North Carolina Department of Environmental Quality-Division of Watcr ResourceI Revised 2-22-2016
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