GW1--03390_Well Construction - GW1_20230515

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WELL CONSTRUCTION RECORD (GNII-1) I For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14:WATER ZONES.
FROM TO DESCRIPTION
Well Contractor Name
3271-A OIP�
ft. ft. IW�
NC Well Contractor Certification Number ®
I5:OUTER CASING(tormulti�ased wells)`OR TIDIER if a"iicable
B &K Well Drilling Inc . FROM TU DIAMETER THICKNESS AIATERtAL
ft- fI- in.
Company Name _
/��0 :16:INNERRASING OR TUBLNG &thermal ebised Roo
2.Well Construction Permit#" FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft, in.
3.Well Use(check well use): ft. it. in,
Water Supply Well: .17:SCREEN -i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. it. in.
Industrial/Commercial Reside 1 YYater�ut(shazed II���YYii�aa,. •� •8 GROIIT _� .•.� ,..,,-. ,,;.;:
hTi atlOn 'L, Z : , �+ ? FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: 0 ft- 20 fL Benote Pour
Monitoring DRecovery MAY 1 .5 ?071ft. ft.
Injection Well:
Aquifer Recharge �GrotleSva lem^cd��fralt,aC[•r= U FROM To ntnrER
_ t. t.
�^(I 1. , 9.,SANDIGRAVEL PACK'd,a li6ble
A uifer Storage and RecoverySalinityBarrief FROM EMPLACEMENT METHOD
Aquifer Test [2Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer -20.DRILLLVG.LOG attach additional'sheets if necesser'':'
Geothermal (Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type-groln size,etc.)
r� 6
4.Date Well(s)Completed:s ' Well ID# 10 tt. V, ft.
5a.Well Location:
42)
Facility/Owner Name Facility ID#(if applicable)
Physical Addres,City,and Zip ft. ft.
�
—County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N W
6.Is(are)the well(s)oPermanent or Temporary 71,91,
rc of c i tc c l o ctor Date
i tg this from,1 h • v cert that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction information and erplain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back oj'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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(g200'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 16el is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
dr� above, also submit one copy of this form within 30 days of completion of well
n
12.Well construction method: ,f 5 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 e• 24c.For Water Supply&Iniection Wells: In addition to sending the form to
ChlorTabs t 1/2Tabs the address(es) above, also submit,one copy of this form within 30 days of
13b.Disinfection type: Amount: 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 I Revised 2-22-2016