GW1--04563_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Joseph Bailey .
.14waTER'zorlEs . �,, u
, F'W;.WVf,•;Z r74.1i.. _ i,,l5g;M.Rx
Well Contractor Name FROM TO DESCRIPTION
3271-A /20fftt' l al ft. 54,19// lferbre,eigre- _
NC Well Contractor Certification Number ��'' ��J f t e/ +"� ?i(f�G
Lk 15:•:OUTER.GASING.(for maltUcased4il s)OR LINE ifwp'ireable) , r.a
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft.
t �41 I ft.
b-,,5- in. sltICa j a r
[ �/^ � � :I6➢.VNER:('ACINGiOR�1IISIAMET Rtitermacaoie NaoS MATERIAL
,V.. ..,,,:
2.Well Construction Permit#: -(' P 1 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: _..1`ti SCREEN. S..,< _.l,..` k-.M 1_ ...�; £ ., o*- ".t. ,„a _<,;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) oResideptial Water Supply(single) ft, ft. in.
Industrial/Commercial OResidential Water Supply(shared)
r,1S:GROUT{,;;x�r_ <<.,,,gr x a, s,.tw sow m a?..:' ta ka;+m:_
Irrigation _ r.-,<==FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
^^
Non-Water Supply Well: P'+1.,,,q,,. 3--..ti V: '. 1..' rt. 20 ft. Denote Pour aA R CS ffp Monitoring DRecove G """ J
LI ty' ft. ft.
Injection Well: i I / I Ot3
Aquifer Recharge J e i t LL
q g Groundwater emedtation ft. ft.
Aquifer Storage and Recovery Salinity Barri@r•„ ^Th Pr ' ° IGRTO EL PeTGK(MATERIALe�x .r i EMPLACEMENT
,; ,, :, D',y z';
h,.n„ ,� FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage''""J ?y' ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ;ZO D1ULLING:Y,QG(attachadditionaIsbeetsifnecessary}
'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type Qrain size etc.)
d r� b ft. )0 ft. /3 e sail
4.Date Well(s)Completed: .c/otiJ/&JWell ID# 140$€ )0 ft. a Cft. -4-0/3 it Q 50461 s f
�'�Jet
5a.Well Location: o ft- ,?e* 44.4 54 1 Sail
n Ile man /hwe S La 0 fL 7o ft. �}elkitiOro',ii15s� `
foil
Facility/Owner Name Facility ID#(if applicable) 9 0 ft. fr.' 6 Q61l?ock
`OfSLon Fcrty/Rol Sylflf6fry1/C• av/4' f' f` Jt95-ft. Gr4•�/!C Ark
t) ft. ft.
Physical Address,Ci and Zip /
R04,0 eel, (j/a z/ 21;REhTARRS.xi?'". `zF, -, < ,,,, c,„::,: „ ,`r t„.« . : , 1 ,' %:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W tr—a0�a3
6.Is(are)the well(s)JPermanent or oTemporary Si use of citified Con or Date
•signing this form,I hereby cent fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with 15A NCAC 02C.0100 or 15A 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'
S��� 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 ifd(fferent(example-3@200'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 Infection Wells: In addition to sending the form to the address in 24a
' above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: t 49/ 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) 420 an Method of test: Airlift 24c.For Water Supply&Infection Wells: In addition to sending the form to
ChlorTabs 11/2Tabs 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 G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016