GW1--03602_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD (GW 1)
For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
14.WATER ZONES Well ContractorName FROM TO DESCiIi:P I juiN
3271-A GJ ft. /(a ft. GPI f�L t n�
NC Well Contractor Certification Number
B &K Well DrillingInc s. UTERCASING formulti-case'awens.ORLINER ifa llcatile
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft' ft 61/2 in. SDR-21 PVC
]6:INNER CASING OR NBING i utliermal closed=lon 2.Well Construction Permit#: fUr (Q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cunstruction pe+mus(i.e. DIAMETER
County,State.Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17i5CREEN<;°
Agricultural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
�Munici aUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
Industrial/Commercial ft ft. in.
�IResidential Water Supply(shared) ,:
Irrigation •. ;;`. .
5 FROM TO MATERIAL EMPL4CEMENT METHOD&AMOUNT
Non-Water Supply Well: Q
ft. ft. / �•
Monitoring Recovery U �G Ov�
Injection Well: ft. ft.
Aquifer Recharge DGroundwatcr Remediation ft. ft
Aquifer Storage and Recove 19_&AND/GRAVEL PACK:tf a cable
rY �SaljnjtyBarrier FROM TO MATERIAL E�fPLACEMENTMETHOD
Aquifer Test oStormwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) �Tracer
I. 20:DRILLING LOG atffieh additionaf shectr if ceces
Ge gP
othermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) FROM TO DESCR PTION(color,hardness.soil/rock type. m sue;eta)
/ 77 ft. / ft. /?e SUr
4.Date Well(s)Completed: �!O O� Well)D#�p��1t2 ft ft.
rdW� O'r
5a.well Location: ft.
ft ft a 4#UU Set I y
aciillittyy`/'Owncr/Name Facility ID#(ifapplicable) ft. O ft-
Physical Address,City,and Zip
SQ&All Ga 'wWoj,fk 21.
a»,
County Parcel Identification No.(PIN) MAY` 2 2 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
it c e• �','u'Xi
N W
6.Is(are)the well(s)oPermanent or oTemporary Sig ure of nifi d 1 Contmc Date
B signing this form,1 herehc cc Jv that the nell(s) was(were)conshucted in accordance
7.Is this a repair to an existing well: Yes or wlrh I5A NC.AC 02C.0100 or 15A NCAC 01C.0200 IFell Construction Standards and that a
Ijthir is a repair,fit[out known well construction information and explain the nature of the copy ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis 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-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: (-0 (ft•) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/fdijjerent(erample-3@200'and 1@/00')
construction to the following:
10.Static water level below top of casing:40
If water level is above casing,use"+" (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter:
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.For Infection 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,
y� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /r I Method of test: t �1 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs 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