GW1--03396_Well Construction - GW1_20230515

P.
WELL CONSTRUCTION RECORD (GW 11 Forll ;
For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey
1'"4:�Wi1T•Eit:ZONES `"' r �,r,��.
Well Con'ractorName FROM TO DESCRIPTION
3271-A L02 ft. ft.
NC Well Contractor Certification Number
B&K Well Drilling Inc souTEx:�is1N>s roFmoitr9cd,�e»S=oRx .8 167� t ,:
FROM TO DIAMETER THICKNESS MATERIAL
Company Name fL G.�S` in.
"-vlo—c `I J d t7��Tl FROM
IPINER CAS(PIN7G OR Tf}BiNM <Eothermal'el r✓osed `" 4 r ,,. -:C t 2.Well Construction Permit#: D FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pei7niij rz.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: h7.SCREENn .�
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL�Municipa]/Public g, ft
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft. m
Industrial/Commercial Residential Water Supply(shared)
Irrigation 18GRt)T7i
FROM 70 MATE RL\L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -.
]Monitoring
�.�, ft- 20 ft' Benote Pour
[]Recover 6 i ,.� . t +' ft. ft.
Injection Well:
Aquifer Recharge pp�� ii Z�23 ft. ft
Groundwate bhledi°atidh
Aquifer Storage and Recovery Salinity Barrier 19'SANDlGRAEL:PAQCs .allcaDie
e r;> 1; ' M TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormtt 'Yr'a �.y.Z z �•�^ ft. it
rr�,,t�>�-•�
Experimental Technology .Subsidence Control ft. ft.
Geothermal(Closed Loop) E)Tracer
E_I' �:20 DRT1;1;119GiT:aG attach addlhdrial sheets if aeces
Geothermal(Heatin Coolin Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness soiUrock a rain size,etc)
�1 / �" a ft. / ft �al C
4.Date Well(s)Completed: 'D Well ID# G 6/ l j �ft. ft.
5a.Well Location:
y . Oi
obi i� 6� ��1_ r_l�cFr-zS 61IJ L�tfi7 H�Gsr l� f� � f` ,-� �,� �a19
Facility/Gwner Name U Facility ID#(i fapplicable) ft. ft. D r fi
by l� c�h)rrir113 / yid �,ot J.h ft. Q t• �G �i/ /� ��G�l
Physical Address,City.Zip / ft ft.
County Parcel Identification No.(PIN) `✓u Lory r�2lL/G l �p u,r C�P
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ruk olj &14i, e 11
(if well field,one lat/long is sufficient)
22.Certifi lion:
N W
6.Is(are)the well(s) Permanent or Temporary Si lure of ertified ell Coctor Date
By signing this form,I hereby ert�that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EINO with 15,4 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 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'
SUBMITTAL INSTRUCTIONS
if
9.Total well depth below land surface: C �. (ft,) 24a. For All Wells: Submit this form within 30 days For multiple wells list a!1 depths different(examp/e-3@100'and 2@1001 of completion of well
construction to the following:
10.Static water level below top of casing:40
1f water level is above casing,use'•+•' (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 ��8 (in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
j 12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
l/(0/�1Tj/ t-;
(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) _ I-0/1_i4,thod of test: Airlift 24c.For Water Supply&Infection Wells: In addition to sending the form to
13b.Disinf Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
ection type: Amount: 11z Tabs completion Of well construction to 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