GW1--03363_Well Construction - GW1_20230515

r 61
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey
14 WATER'ZbNES d•:.a l -.Well Contractor Name FROM TO DESCRIPTION
3271-A ft• ft. ` G
NC Well Contractor Certification Number ft• p'�' ft. f�_J
CQ• r�GTv
B&K Well Drilling Inc FROM TO DER:CA311VG`f DLIAMEETERTER--- tf�ca` etts t)RT1NE1'i} - l le K,
FRO THICKNESS MATERIAL
Company Name ft 0 ft / in.
.21
�?�/ ��/� 1G`IlYNER'CAS#PIGDR'TUBING ` [hernial elosed� _2.Well Construction Permit#: �J 3,J 1 FROM TO DIAMETER IHICKNESs MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
IN
ater Sup ply Well: X2SCREEN �r ,.u °z. �:
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft m
ndustrial/Commercial Residential Water Supply(shared)
M ation GROII'I`._. -
a .- --
FROM TO ,
MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: ,
•y��ft. 20 ft. Benote Pour
Monitoring Recovery a .., a,
ection Well: x �"" 'eft.quifer Recharge Groundwater Rcmodiatl�in 1 r 3ft'quifer Storage and Recovery E3Salinity Barrier �1Vv�I HH 9::SAND/GRiimpACIc da TO MATERIAL EMPLACEMENTMETHOD
quifer Test Stormwater Dranaxperimental Technology Subsidence Controleothermal(Closed Loop) TracertINGTaleothermal(Heatin 'CoolingReturn) Other(ex lain under#21 Remarks) �toM To DESCRIPTION(color,hardness,soiVrock a rem size err)
ft
4.Date Well(s)Completed: 7 Well ID# ft. g,
Sa.Well Location: ft g, -ek /
/ O /
—Z� 1 iq loll/ ft. ft. r/f4a Novi
Facility/Owner Name N Facility ID#(if applicable) ft /O ft 47 r//ram
�ft. ft
Physical Address,City,and Zip ft 4 ft.
oun��Ty Parcel Identification No.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I aiw,7, -110 v G(if well field,one latllong is sufficient)
22.Certification:
N W 4 J
- /
6.Is are the wells 3
Is(are OPermanent or Temporary S• azure a ell Con trot Da
y signing this form,I her certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or EINo with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this 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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'
��jj 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .�7� (il 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
construction to the following:
10.Static water level below top of casing:40
If water level is above casing,use"+" (ft-) Division of Water Resources,Information Processing Unit,
11.Borehole diameter:
6 1/8 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
n 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /(p�/}� 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,
�j 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ O 1�7� Method of test: Airlift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13b.Disinfection e: Chlor Tabs 1 1/2 Tabs the address(es) above, also submit'one copy of this form within 30 days of
type: Amount: completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016