GW1--03604_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD GW-1
..t'ittit�oR
For internal Use Only:
1.Well Contractor Information:
Joseph Bailey
14.WATERZONES. .;.:
Well ContractorName
FROM TO DESCRIPTION
3271-A a ft. . i G
NC Well Contractor Certification Number it ft.
B &K Well Drilling Inc 1s.OUTER.CASINc for multi-cased:m_7b OR'LINER:ifa Hcable : .;. °:. ,;„
FROM TO DIAMETER THICKNESS MATERIAL
Company Name fL ft. 61/2 in.
SDR-21 PVC
2.Well Construction Permit#: � 76 WNEREASII9G OR TUBING eoth'ermateloMR CKNES
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.StalrVariance,etc.)
ft• ft, in.
3.Well Use(check well use): fr ft in
[.eotherinal(Heatin
Supply
Agricultural FROM TO DIAMETER SLOTS17E THICKNESS MATERIAL
r.id
icipaUPublic ft• ft, in.
hermal(Heating/Cooling Supply) Ientiai Water Supply(single)
strial/COmmercial fL ft. in.
Residential Water Supply(shared)
IS*.GROUT non ...
ater Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
D ft. fL
itoring Recovery 4
on Well: ft. ft.
fer Recharge E)Groundwatcr Rcmcdiation ft. ft.
er Storage and Recovery Salinity Barrier M SAI` MRAVEL PACK:>ta (able)
;.
FROM TO MATERIAL EMPLACEMENTHSrETHOD
er Test C]Stormwater Drainage
mental Technology Subsidence Control
fL ft.
ermal(Closed Loop) Tracer
20 DRII LLNG LOG'attich addidoi atsheels if aaces
ermal(Hearin Coolin Return) Other(explain under#21 Remazks) FROM To DBSCRI TION(color,hardness soiVrnck a~ram sue eta)
fL t ft.
4.Date Well(s)Completed:*%U— 01
Well ID# Z-0
Sa.Well Location: tt. fL G7
er Na 0 ft. /�d Qvti/
Facility/Ownmc 0
� Facility lD#(if applicablc) Oft. fL �
Cod
7 V f4
Physical Address,City,and Zip
rU�Q � - O O 21:REMARKS.
•w
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient)
22.Certification: 1niGlrt
6.Is(are)the well(s)OPermanent or Temporary St aturc of crt led Well Co trac r � J ��
Dat
/ signing this form,I herehv ce tifi•that the well(s) was(were)cunso•ucled in accordance
7.Is this a repair to an existing well: Yes or i fj •ith 15A NCAC 02C.0100 or A.NCAC 02C.0100 IYeI!Construction Standards and that a
Phis is a repair,fill out known well construction information and explain the nature gfthe copy oJ'this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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:
I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths ifdierent(example-3C a» ac1001 24a. For All Wells: Submit this form within 30 days of completion of well
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,
11.Borehole diameter:
6 1/8 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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
13a.Yield(gpm) !1 Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection type:
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
Amount: t t/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