GW1--03374_Well Construction - GW1_20230515

WELL CONSTRUCTION RECORD(GW 1)
For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey
14 xWATER tioNEVt s =p. 1,3 k • n
Well Contractor Name FROM TO DESCRIPTION
3271-A �� fc ?% ft /r!f// r3G Krc e
NC Well Contractor Certification Number ft. g,
B& K Well Drilling Inc is:;OUTERCASI;\`c.furmottrcasedvrells;ORLIIYER'if licbl _n ,.
FROM TO DIAMETER THICKNESS MATERIAL
Company Name `y�) A G 0 ft• /" IL /-sue in.
LLC� �V�7 CASING ORSfUBl�I1+TN 'eatheiraia!`e3o 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
��
List all applicable well construction permits(i.e.UIC,County,State,IYarianc,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.r5CREEN r w„ x. M
FROM TO DIAMETERm SLOT SIZE THICKNESSry� MATERIAL
Agricultural []Municipal/Public
fL ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
_ Industrial/Commercial fL ft m
Residential Water Supply(shared) ,
ROUT,,,
hri ation ,.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. ` Q
eenote Pour �J
Monitoring Recovery ft. ft. --
In ection Well:
j t Aquifer Recharge Groundwater Remediation ft. fL
Aquifer Storage and Recovery x39'SANDIGRAVEI gA t rf a" cable ..`, w$ '� • ..x^
rY E]SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft. 1;a;
Geothermal(Closed Loop) TracerZii:DR1T3 tNTiOEi attacisditnerca _ r_ r_
FROM TO DESCRIPTION(color,hardness,solOm k; K
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) e m size etc.
ft.
T `
4.Date Well(s)Completed: Well ID# p/ ft. ft
(y�/
Sa.Well Location: ft, ft• .. rd,,G�Gy/ /'r/ SGa Gr
ft. ,
_ rp
Facility/Owner Name Facility ID#(if applicable) fL 0 ft.
Physical Address,City,and Zip ft. ft.
County Parcel Identification No.(PIN) C!l Yi.QpJ / Ord / a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: RU I d / t&i r!? f� / ��/Q'�46
(ifwell field,one lat/long is sufficient)
22.Certif ation:
N W
6.Is(are)the well(s)oPermanent or oTemporary Si ure of erti ed I Con o Da
By signing this form,I herebv cert fy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or MNo w h 15A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe 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:'
/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (p� (ft•)
For multiple wells list all depths 24a. For All Wells: Submit this form within 30 days of completion of well
ifdifferent(example-3@200'and 2@100')
construction to the following:
10.Static water level below top of casing:40 (ft.)
Ifwater level is above casing,use"+" Division of Water Resources,Information Processing Unit,
i6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (n.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: a ;r LLi-!! 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) r/I Method of test: adtft 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submii one copy of this form within 30 days of
136.Disinfection type: Amount: t/z Tabs completion of well construction to thie 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