GW1--03361_Well Construction - GW1_20230515

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
4
Joseph Bailey 14."WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
3271-A p ft. I 1� ft. 19/ �rj"i LTb
1ep- 3 ;oft. MrJ t4
NC Well Contractor Certification Number �S;ODTER'CASING`fo[inultl-casedlvells OR1 INRR'i#�a `livable#r
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
® ft. ft. /- ,in.
Company Name V A�
'16:`INNE&CASI OR TUBING etithcrntal closed I
�`DP hARY E� 4...
2.Well Construction Permit#:���� FROM TO DIAMETER THICKNESS � MATERIAL
List all applicable well construction permits(i.e.UIC, ouhty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 77SCREEN_'
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public
Geothermal(Heating/Cooling Supply) EnResidential Water Supply(single) ft. ft. in•
Industrial/Commercial Residential Water Supply(shared) 18:GROIJ7;:
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: � e R,gt o ft• 20 ft eenote Pour
Monitoring ORecovery
Injection Well: MAY 1 b N ft. ft.
Aquifer Recharge Groundwater Remediation
C r} :?, 1,f3 1%'SAND/GRAVE(PAGK ifa lica6le ,l-
Aquifer Storage and Recoverylidlfttlfj�eBir7t�r• FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwate rama gge}'13 ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer �20:;DR1L1ING COG atti6li ikidiiiiinal sfiaets
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type,grain size,etc.)
�7 ft. ft. ac G r
4.Date Well(s)Completed: a Well ID# L Lt et. ft.
Sa.Well Location: ft. 0 it. CI a
ft. ,\ ft. 1p
13mw✓J�d�bllr/fel/,filu.Lu v !J
Facility/Owner Name Facility IDA(i applicable) ft. ft. �JAVAJIgOF501
0 I
Physical Address,City,and Zip ft. ft. — e
l l�L./+t►'17 (..(J� 2i:REMARKS<< .::
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.Certi cation:
N W
6.Is(are)the well(s) IPermanent or Temporary Si afore o erti re ell Con ctor D e
signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or EJNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and erplain the nature of the copy of this record has been provided to the well owner.
repair under#11 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-1 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 ifdperent(example-3@200'an 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 Iniection Wells: In addition to sending the form to the address in 24a
J, above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /w�/ 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,Raleigh,NC 27699-1636
13a.Yield(gpm) i0 00 Method of test: Airlift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type. Chlor Tabs Amount' t 1/2 Tabs 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 li Revised 2-22-2016