GW1--03568_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
3271-A Oft.
ft. 3�, It- �
NC Well Contractor Certification Number
15:OUTER ING for mu:CASlti-cased;wells:OR:LINER'ff
B &K Well Drilling Inc FROM To DIAMETER 1 THICKNESS MATERIAL
ft / ft 61/2 1°' SDR-21 PVC
Company Name
16.INNER CASING.ORTUBLN.G e6tlierruakclosed=l `.
y U 2.Well Construction Permit#:_ _ — FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U C.Cotatty,State.Variance,etc.) ft. ft in.
3.Well Use(check well use):
ft. ft, in.
Water Supply Well: :.17
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural KResidential
• al/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) tial Water Supply(single) ft. ft
Industrial/Commercial Water Supply(shared)
PP Y 18:'GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: Q ft. ft 80 6� e QUf /
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge E)Groundwatcr Remediation ft. ft.
1%SANDIGRAVEL ACIC(if a cable'.. '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [)Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach additional sheets if
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) FROM To DESCRI 'ION(color-hardness soil/rock eve rain size eta)
ft. / ft 1
4.Date Well(s)Completed: Well 1D#Lof/bU ft. ft. S a..
5a.Well Location: &11
_*/47Jr!'19J-7 /J47,t5! ` �.!��(/ �7�12✓� ft 1' ft y
Facility/Owner Name Facility ID#(if applicable) ft f- So'-7
I aR C here/ ,a: �o sd,�l� Uc ft. t. V r-
Physical Address,City,and Zip ft. ft — t l r
Jell �'c�,t ��y��-d.t3-1?2 21:R> AR
our( my Parcel Identification No.(PIN) MAY2- 2 1' l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 '
(if well field,one]at/long is sufficient) 22.Certific lion: Infi^�Ti'r;^� t'N� ,,,.a t r r
N W r'
6.Is(are)the well(s)OPermanent or OTemporary Sign re of C ificd cll Contractor Datc
ey signing this form, 1 here..v cerlifi' it the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or Olvo with 15A NCAC 02C.0100 or 15A NCAC 02C'.0200[yell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy oJ'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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `7 6J (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 1@1001) construction to the following:
10.Static water level below to of casing:40
p g: (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
12.Well construction method:
Air Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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: Y I/ 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Ta 1 1/2 Lbs bs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction Ito!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