GW1--03399_Well Construction - GW1_20230515

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
Well Contractor Name FROM TO DESCRIPTION
3271-A asa ft. ft. 5,W4i1 -� vW, Z G
37oft. ft. 4 �Tv� xne
NC Well Contractor Certification Number I5,:OUTER,CASING','for riiultf cased,ell§;bit°LINER(if' �licablel=
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B &-K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. 7 ft. 2]t_ in. d D
Company Name ��J !�
.76::[1VNER.CASINt=.O ,TtIB RING. otliermal closed joo '.v,�.: .
2.Well Construction Permit#: �/ ���20 r / 7!Ij�/ 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. ft. in.
Water Supply Well: FROM�EE TO DIAMETER SLOT SIZE THICKNESS MATERI��
AL
Agricultural rIMunicipal/Public ft. ft. in.
:Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft. ft.
hidustrial/Commercial OResidential Water Supply(shared)
8:G1wur,.',0,,
... _ .. .
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. genote Pour
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [^3^ Groundwater Remediation
. AND/GRAoEL PACK(ifaplin
Aquifer Storage and Recovery Salinity Baer, FROM MATERCIAILtI EMPLACEMENT a
METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILttNG,,1OG attach additiii fikeeti if
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock a rain size,etc.
./� ft, 0 ft. ` r
4.Date Well(s)Completed:jAll a 3 Well ID# 6/6, _ 0 ft. Q ft. 'awrl
5a.Well Location: ` IL br ft. I v Yellow OVY7 4 �L1f
-�le /TINE;z 44 li✓ !•/C ft. rt. l��rsrev le,16I
Facility/Owner Name Fac ity ID#(if applicable) ft. (/�) t. ,;+,j frC a c k
LA1 / a 4611, iV-.a5G ft. ft.
Physical Address,City,and Zip ft.
�sr wbq CO_ e�1�98 d,y&Inv
County Parcel Identification No.(PIN)
11
a, J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient)
22.CertiSca'on: •t-�t�f...
�J N w r7
11
6.Is(are)the well(s) Permanent or Temporary Sign a of C23.
iied Well Contmc D
B signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes 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: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: �Q (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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
�Q T4 above,also submit one copy of this form within 30 days of completion of well
`12.Well construction method: ` 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 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: t 1/2 Tabs completion of well construction to Itlib county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016