GW1--03386_Well Construction - GW1_20230515

WELL CONSTRUCTION RECORD(GW 1)
For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey
14:WATER`ZONFS ...:: ,
Well Contractor Name FROM TO DESCRIPTION
3271-A lv4 ft. %/0' ft. . .
NC Well Contractor Certification Number ft.
lei
B &K Well Drilling Inc 'ls°UrERcasING`"form �a�Ye»s=oRTm�>�i€ lir�tile ��
,F^R�OM TO DIAMETER THICKNESS MATERIAL
R
Company Name �) p/ ft. ft. �a j in r •�,Q�f Jj��
�lt/ ,16Il�3NEGASINGORZUBING thermal_r3os/let1=1" l/
2.Well Construction Permit#: FROM To
List all applicable well construction permits(i.e.UI ,County,State,Variance,etc.) ft. ft. DIAMETER THICKNESS MATERIAL
3.Well Use(check well use): ft. ft. in.
LU
pply Well: 17 SGREEN
turalMunicipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
mal(Heating/Cooling Supply) Residential Water Supply(single)
aUCommercial ftResidential Water Supply(shared) 8'GROUTnFROM To MATEIAL EMPLACEMEN I METHOD&AMOUNT
er Supply Well: 0 ft. 20 ft �_,
Benote our (J �-
Monitoring Recovery
r-A j'•'� I ;.F L7.�v 4 a
Injection Well: _ I
Aquifer Recharge DGroundwater Remediation ft• ft
Aquifer Storage and Recovery19.SAND/GRA[E EPAt3C'Ifa
�SalinityBarrier FROM � To
MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer ft. ft
"21iiiDlttL7;1NG:;L(}G.aftacliadr�rtioialshatslfneces '��
Geothermal(Heatin Coolin Retum) Other(explain under#21 FROM To DESCR
IPTION(color,hardness,so�Urock Remarks) ft ft. e, ram size,etc.
��l 1 v Q 7�
4.Date Well(s)Completed Well ID# �,/1 / SOS
Sa.Well Location: d ft' ft' e//OG(/1 fro
f bpi
��S�ff���/�S
St ll1/./C�l/��//7�f/lily /G. ft N
Facility/Owner Name Facility ID#(if applicable) lJ -ft. /a ft. f-
/- -ply /
Physical Ad ss,City,and Zip ft ft
/ v_ rr R
County /
Parcel Identification No.(PIN) t9/C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certif ation:
N W a
I,301
6.Is(are)the well(s)oPermanent or Temporary Si cure o Certified Well or D e (t
By signing this form,I herecertlify that the well(s)was(were)constructed!n accordance
7.Is this a repair to an existing well: E]Yes or EJNo with 15A NCAC 02C.0100 or 15A 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'
9.Total well depth below land surface:
SUBMITTAL INSTRUCTIONS
_ @ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
if different(example-3@200'mid 2Q100')
For multiple wells list all depths
construction to the following:
10.Static water level below top of casing:40
Ifwater level is above casing,use"+'• (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
I i.Borehole diameter: (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ��n/�i/y� ��� 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
13b.Disinfection type: 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