GW1--03600_Well Construction - GW1_20230522

Print Form,
WELL CONSTRUCTION RECORD (GW-1), For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATERZONES. 1- I
Well Contractor Name FROM 7.0 DESCRIPTION
3271-A
NC Well Contractor Certification Number rrz / Tr4G/
15.OUTER.CASING'(formulti=cased'wells)OIL
R LINER'If a livable
B & K Well Drilling Inc FROM TO DIAM1fETER THICKNESS MATERIAL
Company Name
ft- I ft. 61/2 In' SDR-21 PVC
1'�
�,n /� y ) 16ANNER'CASING OR TUBING. eoth'ermal closed-loo
2.Well Construction Permit#: ,]�•J 0 , / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits FTe.UIC,County.State,Variance,etc.) ft. it.
3.Well.Use(check well use): tt. rt. in.
Water Supply Well:
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural [3Munl I/Public ft. ft.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 18:'GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT J
Non-Water Supply Well: ft. ft. "
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19:SAND/GRAVEL PACK da livable
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
Experimental Technology IDSubsidence Control
Geothermal(Closed Loop) Tracer ...20.DRILLING LOG attach additiooalsheits if aecessa"
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM •o DESCRIPTION(color,hardness,soil/rock tv e, rain size;etc.)
ft. �1 ft. G r�
4.Date Well(s)Completed:bi4RAI Well ID# O /G ft. G ft.
e. ft. 1111 ra 54
Sa.Well Location: i,/.�4
�C� t��li�ll�° / '�a777) ft. ft. /vra S9'ilti O)
Facility/Owner Name V Facility115#(if applicable) ft. �G it. 7iel ItoLl<
✓� ���5�/ �iIIL�n., o/ 6tm/.At dgl 0 -
Physical Address,City,and Zip ft. ft. I*: r=• " x
41yn GG. �� 21 REMARKS
County arcel Identification No.(PIN) MAY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W —e5e�A V-1
6.Is(are)the well(s) Permanent or nTemporary Sign ure of Irtificc6yeff Contract
By signing this form. I heretic c•ei tiij•Jut the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Cnnstruction Standards and that a
/f this is a repair,fill out known well construction information and explain the nature o/the copy r f 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: 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 ifdii feretnt(example-3@200'and 2@100') construction to the following:
10.Static water level below to of casin 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: )1t k f� 24c.For Water Sunoh'&Iniection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Les the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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