GW1--03384_Well Construction - GW1_20230515

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey .14:;WATER°ZONES
Well Contractor Name FROM TO DESCRIPJION
ft. ` ,
3271-A ft-
ft. 2 it.
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NC Well Contractor Certification Number 15:OUTER CASING for mold=caseii wells OR LINER If a" ►icable
B 8t K Well Drilling Inc FROM I TO I DIAMETER THICKNESS MATERIAL
Company Name 4.2 in. CM#?I JOW-
/`/ ���� 16:INNER CASING OR TUBING: i epthermel e►osed-loo'`
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS I 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: l7. N SCREE
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. rt. in.
Industrial/Commercial Residential Water Supply(shared) I8..GROiJ1:?, s
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft. Benote Pour
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge rlGroundwater Remediation
,19:SAND/GRAVEL PACK if;a Itcahle
Aquifer Storage and Recovery [I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer '20.DRILLING Loa attach additiotial`sheets-if necessi
Geothermal(Heating/Cooling Return) r3 Other(explain under#21 Remarks) FROM TO DESCRIPTIO color,hardness,soil/rocka rain size,etc.)
ft. t. Red soil
4.Date Well(s)Completed: Well ID# 'Lot ". U ft. &M-47
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_39ft. ft. ` l® r-aw-I O/
Sa.Well Location: 6q�Y✓s
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Facility/Owner Name Facility ID#(if applicable) ft. 1.011.
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i39 Ly�r�fgr#? Rd_ . Tr6&7m_ s 1W,20/66 9v rt. 3 ft. ,,9 t
Physical Address,City,and Zip �j �/] ft. ft.
21,
7 y-4 — 1 'REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAY 1 U'r
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(if well field,one hit/long is sufficient) 2 Certification:
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6.Is(are)the well(s) Permanent or Temporary Contractor Date/9�1
ysgnngtisform,I hereby c t' that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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-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: 30.E 1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al!depths if different(example-3@200'and 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
�n] T. above,also submit one copy of this:form within 30 days of completion of well
12.Well construction method: /CO/�i/t� 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) Method of test: Airlift 24c.For Water Supply&Injection 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 Revised 2-22-2016