GW1-2023-01865_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name % ft.
Tyr
3271-A 40 ft. /� ft. i//6±a,
NC Well Contractor Certification Number 15.OUTER:CASING for multi=cased=wells OR LINER'if� lksble 7- '7':: "'__
B&K Well Drilling Inc FROM TO DIAMETER I I THICKNESS I MATERIAL
fz ft 61/2 i in. SDR-21 PVC
Company Name n
���/'���e�� ' /��r I INNER CASING OR TUBING' eotbermal'e1osed400 '`
2.Well Construction Permit#: r ,,/v4 D `, FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1G Couniv.State.Variance,ere.) ft. ft. i� in.
3.Well Use(check well use): ft. ft. in.
WaterSn 1 Well: 17: ••
'SCREEN:-•::_ _..: :..:-
Supply FROM TO DIAMETER, SLOT SIZE' THICKNES DATERIAL
Agricultural JoM a Public ft. Ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fz ft.
Industrial/Commercial OResideritial Water Supply(shared)
18.GROUT :..; ..
Irri ation ,, y FROM TO MATERIAL EMPLACEMENT METHOD&AMOAUNT
Non-Water Supply Well: t #c t a r I ft. d ft. en d71' L' PourRidMonitoring Recovery F C`—k "— ''s" ft. ft.
Injection Well: FEB 2. q 2023 ft. ft.Aquifer Recharge DGroundwatcr Remediahon
L
19.SAND/GRAVEL PACK tfa table
Aquifer Storage and Recovery [3Salin*bafnef4�Dr1 trotom TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test [3Stormwater Drai2ge Qi 3O'-i ft. fz
Experimental Technology E3Subsidence Control fL ft. ;
Geothermal(Closed Loop) Tracer 20::DRILLllVG.LOG attilchadditionalsheelsi&aeu
FROM TO DE.SCRIUION(color.hardness,soi0rock e•grain size,etc)
Geothermal(Heatin Coolie Return)
�j Other(explain uun�der#21 Remarks) ft. v fz Rd SQ
4.Date Wells)Completed: /J �X Well LD# 4��N� fz ft. �
5a.We Location: ft. ft. e fl 1
G� fz � It.
Facility/Owner Name Facil' ID#(if applicable) too it. ft. f
Al
t: e/v ft. �0v 1
t' ft. ft.
Physical A ss, y,and Zip Wry
/ /no
-✓J / 21.REMARKS `'
County Parcel Identification No.(PIN) _ v�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Q� 1 �e +'4G (/!
(ifwcll field,one lat/long is sufficient) 22.Certific lion:
N Wtm
6.Is(are)the well(s)oPermanent or OTemporary Stan ro of'96rtified Well Con Datc
A signing this firm,1 herein Certlfti'that the trell(s)rtas(were)constructed in accordance
7.Is this a repair to an existing well: OYes or RNO wish 15A NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
Ifthis is a repair•fill out known well construction information and explain the nature t1 the copy to*rhis 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 NUMSER.of wells construction details. You may also attach additional pages if necessary.
drilled: t SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: / -26 , (f-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifdii ferent(example-3@200'and 2Cia 1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service C inter,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.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Aaleigh,NC 27699-1636
�{`�j�
13a.Yield(gpm) !/V!'e f Method of test , /i• � 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subinii one copy of this form within 30 days of
13b.Disinfection type. Chlor Tabs Amount: 1 1t2 Lbs completion of well construction tol the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resour Ies Revised 2-22-2016