GW1--03387_Well Construction - GW1_20230515

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
Well Contractor Name FROM I TO DESCRIPTION
3271-A k• ft. I .GiZ ��
NC Well Contractor Certification Number
15 Uil F1rR:Ce?SING`MV'm i ed weds iA1t I QIE11 t#"
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS I MATERIAL
Company Name Jan
0 ft. ft. g 1/2 ' in, SDR-21 PVC
dtl/d(wSla7 �'� 7 '^?6rIl�Ii�IER,G�SSIL1G0R%Tb-B1NG tbermalc3®setl=l : ,.rr (r
2.Well Construction Permit#: 6✓ FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State.Variance,etc.) ft It. in.
3.Well Use(check well use): ft. ft. in. J Gi
Water Supply Well: �.:. . t.,
FROM TO DIAMETER SLOT SIZE THICKNESS. MATERIAL
Agricultural [3Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) 1 enttal Water Supply(single) is
Industrial/Commercial Residential Water Supply(shared)
s a.
hTl ation _.- 4"^, 1'�e.. OM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: r fL
Monitoring Recover -.
ry r ft. ft.
Injection Well:
Aquifer Recharge Groundwater Rcmediation V00
ft. ft.
Aquifer Storage and Recovery 1g3Salini
t tY FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test []StormwaterDrainage ft. -ft.
T
Experimental Technology Subsidence Control ft
Geothermal(Closed Loop) Tracer
;Zff- 121LL'IN1f-1:OC.'`att5ch�t1dltr°ii$Isheefs3ftre ";:s._,� ktx r..�:l s
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc
ft ft la,•
4.Date Well(s)Completed:/dfa Well ID# V
7
5a.Well ocation: ft. �l ft. Q
ff V
/� fQm�s GfI 9r1dPi U f` dIL
4
Faetlity//Owner Name Facility ID#(ifapplicabl ft- �n G
#&-47d L 4 Al�4 �I � �C ����/ ft. ft. iC
Physical Ackiress,City,and Zip 'f (� ft. ft.
�l y��L/O`���// !.2I`.':•RE1tSAR1=CSi ., .. ..'::�, ..,, .,... • ., . •_�,; ,..�::. r :,:;».t r.
'County Parcel Identification No.(PIN) �+-T • s✓
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica' q
N W
6.Is(are)the well(s)oPermanent or Temporary cure of rtified well Contra or Date
y.signing his form.I hereby cer' •that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or o with 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 of the copy ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis 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:
('�I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ' ({t-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample- 00'and 2@100') construction to the following:
10.Static water level below top of casing:40 {t,
( ) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 �$ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Air Rotary 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:
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: AY Afr 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs 1 112 Lbs the address(es) above, also submit one copy of this form within 30 days,of
13b.Disinfection type: Amount: completion of well construction toi the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016