GW1--03362_Well Construction - GW1_20230515

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: " �) OR
I.Well Contractor Information:
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Joseph Bailey
>14 WATERZU11tES Well Contractor Name
FROM a,.�-.... F.a.,,......;:
TO DESCRIPTION
3271-A
ft.
NC Well Contractor Certification Number
B&K Well Drilling Inc �XM.VU, x�CA c°for•muleeas�a el o1r1Lm>iriz, a l n>e ._--
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft ft. in.
�/►n �/ FROMT7SIAM 2.Well Construction Permit#: !I1P FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: „17 SCI3EEN,,,,ys
Agricultural FROM TO w DIAMETER" SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft ft. in
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single)
ft ft m
Industrial/Commercial Residential Water Supply(shared)
_ _ 18`GROII,'1'�s.,.0....» x .,y.�.,.;.;:z. . .:..._'. .. z. �.•> ,'t`.. '?..[
hri anon �"-".;, -t�'�' :� f `v 1120M TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 4 •,=5 fa 20 ft
Benote Pour
Monitoring Recovery ft. ft.
Injection Well: .. ,
Aquifer Recharge Groundwater RemPP��iat�
§SANDlt>l2iLYEL"1?AGK a livabl
Aquifer Storage and Recovery � L't•" i Y`
Salini amen �.lu lyj FROM TO MA e TERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft• tt.
Geothermal(Closed Loop) Tracer
ZO:-DRIB:IN6`IQG°atlachaddibnpatshects>3f'ueces t"` .,,....W: ,,.,;�z�;�,•,,;;,
lGeothermal(Heatin Coolin Retum) Other(explain under#21 Remarks) FROM To DESCR ION(color,hardness soil/rocka ram size etc)
ft, ft
4.Date Well(s)Completed: t Well ID# G ft, f �o
5a.Well Location: �/ ft. ft• r�/Oi✓ row/ SO
AyAlh/ ft ft. ro
Facility/Owner Name Facility ID#(if applicable) 20 ft y501ft w
ro /
Physical Address,City,and Zip t ft ate' C ack
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ram✓ Ce �C /f/�l/w //,, 1,w
(if well field,one lat/long is sufficient)
22.Certification:
Q
6.Is(are)the well(s)oPermanent or DTemporary Si tore o ertifie Well on for Date
signing this form,!her ,•cert(fy that the well(s)was(were)caruitveted in accordance
7.Is this a repair to an existing well: 13Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature of the copy ofthis 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-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: C 1�� -(ft-) 24a. For All Wells: Submit this form within 30 days For multiple wells list all depths ifdifferent(example-3@200'and 2@100') of completion of well
construction to the following:
10.Static water level below top of casing:40 g
lfwater level is above casing,use"+" (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: o/q 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
t 1l2 Tab 13b.Disinfection type: Amount: s 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
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