GW1--04562_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1 .
1.Well Contractor Information:
Joseph Bailey
1.14>WATERJzoNES :m a x t 4 1 t C r.�..; 5 a.er A�`x5
Well Contractor Name FROM TO DESCRIPTION «�.
3271-A f0 ft. 9 3 ft. i44,te.
C✓v a/
NC Well Contractor Certification Number ft. ft.
B &K Well Drilling Inc 15^MU3'ER-frYS1N>:(for;multikiWdtialaIOR THICKNESS
(if'ipipltMATERI E,.lF,f`.`:{rwtc.;k
FROM T/O ft. I DIAMETER TICKNE MATERIAL
Company Name 0 ft.
t i
y t �J`C7�_ m L►/1Q A f ( WC.
/� `'yit� �� i1.6'.IlVNERCASI1 GOR1T1111.01G'(geothernfat_ etJtiiii -poop) I;;.,,n/_ k t i f„ti 2.Well Construction Permit#: L r _l 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 SGREEN ` F.. ., r,, ..gas;r ...
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
EiMunicipallPublic ft.. ft. in.
Geothermal(Heating/Cooling Supply) EtResidential Water Supply(single)
fG ft. in.
Industrial/Commercial DResidenfial Water Supply(shared)
Irrigation — FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G,�,= L' ; , ..l r / 4' `#/I
t �kry S,F 4•_,y a� � 0 ft. 20 ft. Benote Pour V J
Monitoring Recove
Injection Well: ^}(� ft. ft.
AIL112J ft. ft.Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery ow a•�I BaaiiT'ert;�7 .r •. 1.3 I•f�� ..14;.Si L•TDICItA[ LPiIGI"[dapjilicable}) K'` x... ..� S t ' to '
it r`.i r .-;23, FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater'Iirainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
,.211 D1t1a NOLM at6acl iftldit iiii`al`sheets°i iii0iiiiry if n1=Wi;a: „t
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sowrock type grain size,etc) ~
�/y d3 ® ft. ft. lac Soy 1
4.Date Well(s)Completed: / Well ID# o/ / 5. ft. /Tit. firmodn COS
5a.Well Location: e5 ft. 30 /c ft. .�
�J am kirow4 540101ySot'l*.e i
jwi€3 Rizzo Rom oaf/larif 30 ft. GO ft- .Sa'R Oh&a l Rock
Facility/Owner Name Facility ID#(if applicable) L)ft �f^N n /'T ,ie �(na G.
)�� 4ti14e4ke., /c44ngprid� ,/I4 a�I�o�' v ft. ft.
(J
Physical Address,City,and Zip ft. ft.
)� 21.!REIFL�RK5.; ,.�. i d
IJLrIS�J Ca• c27/E' / �� ,. . _. ....,� . ,.`F €!mmian,wri;st
ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certifi Con:
N W
6.Is(are)the well(s) Permanent or Temporary Sigma%a ofC ifeed Contract r Date
By;'gning this form,I hereby cert that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E@No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 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#21 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 I GW-I 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: 03.. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')
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,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /?6 / 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) 340 0 Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection Chlor Tabs 1 1/2 Tabs the address(es) above, also submit one copy of this form within 30 days of
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