GW1--04560_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14kwATERZDNES. ,._ ..,q PWWW r 6 ; - 4 r.:
Well Contractor Name FROM TO DESCRIPTION '.,
3271-A •
/ fr- / f So. /rltl r, �'4seTtc.2ag�
NC Well Contractor Certification Number c Js7 ft �q�t• siyAfe
��
15 OIP£ER:CASING4:(for.mniti*IiieI wellsyOR3ANER'(ifa licahI *jz ..w,.,:-
B&K Well Drilling Inc FROM TO DIAMETER THICKNESSHQ AiTERIAL
0 ft. ft. ��s-- m L 1 d 7. /U6
Company Name
C�� -16:'11YNER•C ING.OITUBING(eothermal'cCosed-lugili � i' .,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, ariance,etc.) ft. ft. to
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:?SCREEN � +,_ F, ..e ?.. € ,. 3
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
. Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) tt ft. in.
Industrial/Commercial DResidential Water Supply(shared) i8F;GROUT fifi -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft* Benote Pour 26 iiP
Monitoring 0 Recovery ft. ft.
Injection Well:
ft. ft. 'C., '-' —:,..
Aquifer Recharge ti,' _ : ';
9 g Groundwater Remediation • - •
Aquifer Storage and Recovery :19 SAND/GRAS L.PACK{ifapgifcabfe) .,„.: it " ..ti v l,,.,?'>g;��.';k m.,.r,,,.�:3A`,, ,
q g 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EtStormwater Drainage ft. ft. JULI ! LU a
Experimental Technology OSubsidence Control ft. ft.
Loop) (n " i t f•a
Geothermal
(Closed Tracer 2Q71!i�1.LllN±G'TiDG�(nttiici'►:addititiiisl'sheetaa€tecestge3fe F"�"�" ,�:-i
Geothermal(Heating/Cooling Return) FROM TO DESCRI ION(c 2r,hardness,soillrock type,grain size,etc.)
( g/ g/ nOther(explain under`er#21 Remarks) (h/ ft. /0 ft. {�/
4.Date Well(s)Completed: Q�j/V Well m# LO /4 !d ft. cit. 4t4,Ste I
P
Sa Well Location:Ld //(� L //1�t• tt. �,fi"` s Q�s¢{/Tr (+/4 &fle 11/re s4 Oifoft. ft. e v 16497 Spa '�+�'Facility/OwAer Name Facility ID#(if applicable) sd ft /.JI ft 5 r aoc fC
/35O Ca l] Or ,j /'Youfrilim NC,29 Ga. ft. )o3'ft. /-vt 17rck V'
Physical Address,City,and Zip ft. ft.
l 1✓yn CO , Srrb OW 21:R> .i . .
County Parcel Identification No.(PIN) SM4 4 five f/ti Z/me t s-5.5 j?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient) 22.Certif ation•
N W
6.Is(are)the well(s)JPermanent or OTemporary Si tore of ertified Well Contra or Date •
v.signing this form.I hereb• rtify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EiNo with 15A NCAC 02C.0100 a 5A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2l remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'
J��, SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v (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 00'and 2@100') construction to the following:
10.Static water level below top of casing:40 (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 Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: y/\6- above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) •
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I a 04 Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 t/2 Tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016