GW1--03565_Well Construction - GW1_20230522

Prins Form
WELL CONSTRUCTION RECORD (GW-1) For Tnternal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.`WATER ZONES.
Well Contractor Name FROM To DESCRIPTION
3271-A • ft. 91 ft. . 1 �a
ft. rt.
NC Well Contractor Certification Number 15:OUTER.CASING:foi arulti dsod:wells OR LINER'•ira' Ilcible
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 19 ft. So ft- 1 6 1/2 in. SDR-21 PVC
&INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit# 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunici al/Public ft• ft, in.
Geothermal(Heating/Cooling Supply) eside'mial Water Supply(single) ft. ft.
lndustriaUCommercial Residential Water Supply(shared)
-
PP Y ) 18.GROUT `<
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. e17 Nk 0
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge [3Groundwatcr Remediation
''19:SAND/GRAVEL PACK Cif a llcable ',
Aquifer Storage and Recovery ®ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING,LOG attichaddttiooilsheets lfbecessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type.gmin sin;eM)
ft. ft.
4.Date Well(s)Completed:01/c Well ID# Ta+✓
ft. ft. `/ ✓ ` /'Q
Sad.Well Location: Ga., /
0 L
�J
/{L ll �i �!/�/ QL✓�✓1 �'l �l! ft. f
Facility/OwnerNamc Facility ID#(ifapplicablc - ft. fL d Uri
1/� S�rtYki Uizt/L 5�'!�s S d�%0% r� S s rt. ft.
Physical Address,Ci and Zip ft. ft. T ` ti'
21.:REMARKS '
gut .3 �aa� ^A
County Parcel Identification No.(P1N) MAY 2 07�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l r,
(if well field,one laUlong is sufficient) i rep�-�•�� � � ,-,�,:.v;r
22.Cc '[cation&,4
N W
6.Is(are)the well(s)0 Permanent or I•Y. Tem ora urc Ccriificd Well C ractor Dat
P I
A.signing this form,1 hemb.v certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or a 'v with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction informaiinn 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-I 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3�)a 200' nd 2 c 100') construction to'the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
/'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) "
24b.For[niection Wells: In addition to sending the form to the address in 24a
Air Rotary 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 len,ter,Raleigh,NC 27699-1636
._ I
13a.Yield(gpm) 2 ! /Method of test: 24c.For Water Supply&Injection 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 Lbs completion of well construction to 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