GW1--03393_Well Construction - GW1_20230515

( Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14-NVATER+ZONES
Well Contractor Name FROM TO DESCRIPTION
3271-A ft. 3 I.
NC Well Contractor Certification Number I Oft-
/�I ft. ed ��G.5v� r,e
'd5.OUTER CASING formultl-cased'-wells OR LINER(if AID licable -
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
® ft. /D r ft. in. L
Company Name
76::INNER CASING OR TUBING" geothermal closed-loo
G/ a 9-ao��- 1o2
2.Well Construction P¢rmit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in•
Industrial/Commercial Residential Water Supply(shared) 18._GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Benote Pour o
Monitoring DRecovery ft. ft.
Injection Well:
.c
ft. ft. .
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL t9't SANDIGRAVEL PACK if a li
IAL V I EM Le>LrSE i D ETHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft. In t fir,-r':3il t °'`'':''Z'-:;g Un;i
ItiiA iv2�
Geothermal(Closed Loop) Tracer 20'DRILLING-LOG attach additiaiialsheets itnecessar
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)_]
emarks) FROM TO DESCRIPTION(color,hardness,soillroch a rain size,etc
ft. /Q ft. e' Sail
4.Date Well(s)Completed: Well ID#G®T !/o 0 ft. ft. l l)L,► tl Qi
5a.Well Lo tion: a ft. /J ft. LlC Aw / IUWn fl 1 y{
iVBS �OnaCS LLG St✓l�� G rt. 7 ft. rl / �o c
Facility/Owner Name p� }�A Faaci iQ ID#(iff a/pppllicable) j ft. ft. ` J +� t /
110. LGI/f �///'1�1/r�//1 fJ/(IrG//. /YG.� lO, v w
Physical Address, ty,and Zip gg��//�� �� ft. 'WO ft. 17 `e Rack
CsTwb�. �_ J//7� 0ol01,S�4 2I:REMARKS
County Parcel Identification No.(PIN) /rit ,d V-r ve !��®
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4 H /& 1 /yMO a d I,? Q/M4
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) Permanent or Temporary Sign rc of ertifi 11 Con for Date
By signing this jam,I h reby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ONo with 15, NCAC 02C.0! 15.4 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#11 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 I 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: �t/J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(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 Iniection Wells: In addition to sending the form to the address in 24a
!� -f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: O/R 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) OI Method of test: Airlift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs Amount: t 1/2 tabs
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction Ito 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