GW1--03406_Well Construction - GW1_20230515

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey i4:VvAiER:�C)19ES . s
FROM TO DESCRIPTION
Well CORtIaCSOr Name
Q
3271-A J ft. a'4x ft. 76
ft. ft
NC Well Contractor Certification Number
,15'.0,TITER CASING for.multi.a s d elit"OR',LINER;
B&K Well Drilling Inc FROM TO I DIAMETER THICKNESS MATERIAL
ft. ft.
in. ! /
Company Name /elf
/e/B — �� I�S/v �6;INNER CASING OR'Ti7BI1VG."egtti a anal
2.Well Construction Permit#: f�ri 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: 1�J:SGREEN..M•. R�.�.. u _ ..� ;_ _ _.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. tt. in,
Industrial/Commercial [3Residential Water Supply(shared) tg�ROtif3 fr y} __:
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft- 20 ft. Benote Pour
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
,19i,SAND/GRA,VEL�PACK' fa' licable
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) 13Tracer 26s1]RILTjiNGLOG'.attachaililltigtialsheets•if.riecessa ' s.'.<
FROM TO DESCRIPT N(color,hardness,soutrock e, rain size etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#221 Remarks) Q ft. ! ft. Clt 0
4.Date Well(s)Completed: Well ID# 1—or 4z— ft. ft. '//
5a..Well Location: lkv
Ale4 &W[ vj'c WOW-
J 6 / �
Facility/Owner Name Facility ID#(if applicable) ft. /` ft.
340Y rnYl&,e-17&W 4,4/, ,/W4J;W IV o-1 OSD ft. aV ft. QL
Physical Address,City,and Zip (�c �] ft. f
/ ��/ 6 a✓� C,d_ .J Y/I o ®7�l ! 7 d` +21:RF'MARI S';.„ y a a.1.�a..��,E:,3 e, e-':s a,-'�'u a..:b n Mkt v F .r,•.i,a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAY
(if well field,one lat/long is sufficient) 22.Certifcation:
�IfI�G 7.,rc�,n:i"� ni nn
ra. r s� t r.; t• c� Oi
N W � A
,ra:a'Ir2t'�'Ou
6.Is(are)the well(s) Permanent or OTemporary Sign Fure of Cftified Well Contractor Da e
By signing this farm,1 hereby cei that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or RNo 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#11 remarks section or on the back of this form.
23.Site diagram or additional wetcletails:
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: . A) 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@1001 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: ,[�A/d 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) !7 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016