GW1-2023-01907_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 TO DESCRI riON
3271-A 00". 0 117,tt. SM411 d Al e 0;
n ft- ft-
NC Well Contractor Certification Number 01� 440-1 5o�l
"I cased wells OR LINER'it ap le
.15.OUTER,CA ING for
B & K Well Drilling Inc FROM V TL1111--lIETER PTiTLICKNESS !UVTERIAL
Company Name 0 61/2 SDR-21 PVC
'OR TUBING(geothermal closed-lotioll'..
it Wgil Construction Permit#: 1,f 16.INNER CASINGOR lell- FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable%tVll MM(rliclion permits(i.e.UIC,County.State.Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
v,
A.T,SCREEN
Water Supply Well, FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
f.Agricultural [3Municipal/Public
Geo
thermal r I'hernial(Heating/Cooling Supply) &sideritial Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) '18�GROIJT
Irrigation FROM TO MATERIAL EMPLACEMENT 51ETHOD&.AMOUNT
Non-Water Supply Well: It.
3Monitoring ORecovery ft.
Injection Well: ft. ft.
:3I
Aquificr Recharge [3Groundwatcr Rcmediation
PACK ffapplll cable)u
A uifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Ejerimental Technology [3Subsidence Control
Geothermal(Closed Loop) [3Tracer 20.,DRILLING LOG`(affich-ddithiii-1 sfi9 it9 J If
FROM To DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
lGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) e S 6Y
4.1 ate Well Completed: Well ID# ft. TO L
ft. &rav
5!Well Location: 89 460fft- Ro6k
J-0"Alt? A�(`)Ile r- ft. I ft. — — — —-1
Facility/Owner Name Facility ID#(if applicable) ft. ft. U t:ii V t
ft.
-ZeA zil& /V 0 JiLdw-8) - ft. FEB 2 ILI 20B,
Physical Address,City,and Zip ft. ft.
pM
21.
(-7a
REMA
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Lr-"7- 4`71
(if well field,one lat/long is sufficient) 22.Certification:
N W
411-0
6.Is(are)the well(s)oPermanent or [3Temporary Si at re of crtifi d*ell-Contra C Bale
ur 'nf ' "
signing I is form, c rfify that the ivell(s)wav(were)constructed in accordance
Si
A 11 '5A NCAC 02C.0200 Well Construction Standards and that a
with 15,4 NCAC 6 -
7.Is this a repair to an existing well: Dyes or MNO fN�
If this is a repair,fill out known well construction information and explain the nature 00he copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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:
b 111ri SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: bi W-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'aid 2@100') 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 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: In'addition to sending the form to the address in 24a
12.Well construction method: construction to the followi4 Air Rotary above,also submit one co i pyl of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) :-
I I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail i3eivice Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ I UK Method of test: A kP07— 24c.For Water SuvolyWInoection Wells: In addition to sending the forni to
I the address(es) above, hlsb submit one copy of this form within 30 days of
Chlor Tabs 1 1/2 Lbs I I
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. 11
Form GW-I North Carolina Department of Environmental Quality-Division of WatcrAcsources Revised 2-22-2016