GW1--03400_Well Construction - GW1_20230515

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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 ay. 24117ft.
ft. ft.
NC Well Contractor Certification Number 45-OUTER CASING,foe;multi-casei]`wells OR'LINER'ff a iieable
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS M TERIAL
Company Name ft. / 4.Ar in. OR 21
/�,� J 1•J/��(nh,�1J� l6:INNER CASING OR TUBING eothermai'closed-loo
2.Well Construction Permit#: Illy I Vla - t70f7 - 'i /�GIV V� FROM TO DIAMETER I THICKNESS FMATERIAL
List all applicable well construction pen its(i.e.VIC,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 nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irri anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ec. 20 ft. eenote Pour
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
49.SAND/GRAVEL PACK if applicable),
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer '20.DRILLING L"OGI attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type rain size,etc.
40 ft. ft. e
4.Date Well(s)Completed:3/ well ID# !,io ft. ft.
5a.Well Location: t. ft. ` el/ �� �l/ s�
W"/ �� G C 10
rc. ft. G. a
Facility/Owner Name Faci ty ID#(if pplicable)
ft. ft.
Physical Address,City,and Zip �l
cfA,,bf Co. j L/�®y�l t3�o� IL RENIARKS`
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAY 1 O
(if well field,one lat/long is sufficient)
22.Certification:
N W t1QG"iY,s Sn Pr: v^CirP• i :S
z� r'. Qr IXII
6.Is(are)the well(s) Permanent or Temporary stg tore of C ified Contractor e
B signing this farm,I hereby certi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or E)No 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 eonsnuction information and explain the nature of the copy ofthis 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
9.Total well depth below land surface: 3® (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: d �n� 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: 1 1/2 Tabs completion of well construction to the 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