GW1--03601_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD (GIN 1) n1O
or Internal Use Only:
I.Well Contractor information:
Joseph Bailey
14.WATERZQNES.
Well Contractor Name FROM TO DESCRIC,r10N
3271-A ft.
NC Well Contractor Certification Number >Oft. a Il ft. Gam'^e—
B &K Well DrillingInc OUTER...SING_for multi-cased. ills:OR LL1INER wa Hcable : ^:::,•;
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. (� ft. 6 1/2 in.
n i SDR-21 PVC
!I_J / `��� 16.1 INNER CASING OR TUBING. eothermal closed-I
T
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.•":;. .,:.. .::..
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS• MATERIAL
�Munici al/Public
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft• ft in.
Industrial/Commercial Residential Water Supply(shared)
Ig GROUT
Iiri Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.MOUNT
Non-Water Supply Well: v ft. () ft. T -7—
Monitoring Recovery Ci9Tli /� tJ�
Injection Well: ft. ft.
Aquifer Recharge [3Groundwater Rcmcdiation ft. fL
Aquifer Storage and Recove 19&AND/GRAVEL PACK d a cahle
rY Salinity Barrier FROM TO MATERIAL EMPLACEtviENT;1fETHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) 13Tracer 20 DRiLLINGLOG attachadditionalA__ts,Pifaeies
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hacdnes>_sorVrock e, m sime etc)
i P
4.Date Well(s)Completed:� Well ID# LO� /t� ft. rft.
J rd LIn 0 i
Sa.Well Location: S tt. fL e 4/
�I�nJY✓�Q•/ �� or /�t� �7TA7f fL v fL �e !•e OG I'1/ V4
Facility/Owner Name Facility ID#(ifapplicablc) 0 ft. 00 ft.
1' 9, e
/o/�e/I'rtXY ,r;�r ;� /�a ly� f. fr.
Physical Address,City,and Zip d ft. ft.
21
:.REMARKS ' t
County I 1
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees •� -;,; i!r
(ifwell field,one lat/long is sufficient) ;
22.Certjfication:
N W a✓ /��
6.Is(are)the well(s)oPermanent or Temporary nat of Certified W 11 ntractor Dat
Br signing this form, !h ebc certJf that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or �iVp with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 iYell Construction Standards and that a
Ifihis is a repair,fill out known well construction information and explain the nature ofthe 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:
_30S I 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 ifdierent(example-3@a 200'and 29100�
construction to the following:
10.Static water level below top of casing:40
lfwater level is above casing,use'.+•' (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b. For Injection 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
_ 1636 Mail Service Center;Raleigh,NC 27699-1636
r
13a.Yield(gpm) Method of test: /� ��� 24c.For Water Supply&Injecton Wells: In addition to sending the form to
13b.Disinfection e. Chlor Tabs the address(es) above, also submit 01nei copy of this form within 30 days of
type: Amount: 1112Cbs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmcnral Quality-Division of Water Resources
: Revised 2-22-2016