GW1-2023-01906_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
Well ca a=wax�xzoN>rs •;� :;�-�;_'
Contractor Name FROM "I
TO DESCRIPTION
3271-A Oft' a!D
NC Well Contractor Certification Number ft.
B&K Well Drilling Inc Is::o1rFER:GASING:tormtild rasedtvet)s ORIb11VER:ifa`"livable
FROM TO DIAMETER THICKNESS MATERIAL -
Company Name ] �Q ft bt ft' 6112 in. SDR-21 PVC
l,,?/eGl I�'of���" I��" �16 IIVNERiCASING;ORTUBING. eothermal'ciosedaoo
a.Well Construction Permit#:_ FROM TO DIAMETER THICKNESS MATERiAL�'
List all applicable well construction permits UIC.Colrnty.State,Variance,etc.) ft. ft. in.
&Well Use(check well use): fr. ft. in.
Water Supply Well: 17:SCREEN:_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agriculturnl �Munici al/Public ft. fr. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft.
Industrial/Commercial Residential Water Supply(shared)
•r...;;:. ;:_.'!.- ::<:::�,..�:.,�,__:; �::.;_.,,r: ..... ..•:",.........
Irrigation FROM TO MATERIjdgrAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: ff v f� �e v�
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge ft. fL
q g Groundwater Remediation
AquiferStorngeand Recovery Salini Barrier i?'SAND/GRAYELPAG[C tfa cable';_.,'>_`:':•':;;i:;::' ;°:: ;';v, r-,::'l;r±;:;"•:;
ty FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test Stormwater Drainage ft. fr.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) T
racer 203DRU IINGtOG attach sidditiorialskeeisitue
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPI.ON(color,hardness,soittroek type. "in"size,etc.)
1 ft. fr. RA OJ"
4.Date Well(s)Completed: Well ID# /-Ol &A ftA�*
Od
5a.Well Location: ft.
_ / r � o
FacAll
iAlity`//Owner Name �%Irr&ax'OWIC
/� Al
Faacili DD#(iffaappl Qplicable) D ft. l� fr.
Physical Address, lty,and Zip A ft ft.
TC� �1G ,S"�?!/d ,ai:RE1KARxs ' .: •ol=� a;° _ �<;� _- _
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.Certification:
N W
6.Is(are)the weA(s) Permanent or Temporary Sig trot o C ific 1 ContV, y
A�2_c�'
Date/
8 signing t is jorm,/hereby cat the wel!(s)was(were)constucted in accordance
7.Is this a repair to an existing well: Yes or 7h ISA NCAC 02G.0l00 or 1C 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 io the well owner.
repair under#21 remarks section or on the back ojthis jorm.
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:
�t �f9.Total well depth below land surface: (f�) SUBMITTAL INSTRUCTIONS
For multiple wells list all depths 24a. For All Wells: Submit this form within 30 days of completion of well
if (example-3@200'a»d 1@l00� construction to the following: ,
10.Static water level below top of casing:40 ft.
( ) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+•' 1617 Mai!Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1 I8 (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 form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: /� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Q I'/ Method of test: y' `/r 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, alsol stibmit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1t2 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 Resources Revised 2-22-2016
1 I