GW1--04568_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD (GW-1) J - oa m;#
For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 44::dmsrEitzons n... iff i «a wa,::; -ac,...._ is u i my .,a -__.
p
Well Contractor Name FROM TO
DESCRIPTION
3271-A I a ft I ate` if e ,r4rTor-ze to
CC
NC Well Contractor Certification Number ' 7tl ft.
t //jtfr tie/ e
B&K Well Drilling Inc 15'_QIIT>rwegsmG(franiiiii is )oxt1N.i. a n
FROM TO DIAMETERLiTrHICKI4ESS.. ANIT R '".^�,r r MATERLIL
Company Name ft C�o L f �9 e✓m .014'1 �,/e
/" I'6."INNER" ASINGDR'TUBINC:O:(�iiiiiermatcioseZlooji) (/ I 2.Well Construction Permit#: �� 37 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: L7eSCREEN ',r. t„. . fit.., ti r..... .'n�'s,m,.,x.x.;„i i�...,i.I s r w i a,N.''
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
It. ft. in.
Industrial/Commercial Residential Water Supply(shared)
Inipation :18:`GRULJI`,.. �:. , s,s =.s=`.L": 5... avc nm iz n a.J._,.,;5 ' i ...tw, 4�'.., Y
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL
Benote Pour -,� /� ii/�
Monitoring Recovery ft. 't k
Injection Nell: ft.
Aquifer Recharge ft ft. ( 'N.:,a.,l,,,,a..i `l" :1— ',.Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier -d97 SAND/GRAVEL:PACK(if applicable) ,t t ` cs��jj��rr rtt. t ,
liaallVi
FROM TO MATERIAL ,1 i 1 I EMPI/ALEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft. I I;gC;i::lil;,:,i
Geothermal(Closed Loop) Tracer r`k °,
24 DRILLINGIAGIn.tftiefi nddliiibill sheefsIfnecessarffli eW f".,<,Y;I
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCCRIPTION(color,hardness soil/rock type,grain size,etc.)
/3'l 3 13 ft. /o ft.
i
ed sT'l4.Date Well(s)Completed: / Well ID# 40� /0 ft• ?e+ft. „el
cJta
5a.Well Location: 3s-ft. / fir) ft. lief ` s��� s�,�
fi�e/msni44#07/ a . (9 6f ft. (/(c,/! ft. p,ar• i ear
Facility/Owner Name I Facility ID#(if applicable) Q�ft. T,,S�ft. ne /l 4 LJ J - r I �/
g /$ 54ffriliffevri ?d iske fizawo f45-ft. /j/1ft. ,(P_`'i7�9/106Q . s0+'!Dj♦/�(y%
Physical Address,City,and Zip , ft. V ,Q /
/2� 1 GO ys(o PIO l o a eft.,G r1� gdzr�
.:3 A IMet-.,,
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.Certifi�row
6.Is(are)the well(s)JPermanent or Temporary Signs o40e16f Ce ified 1 Contract 0437
By s'ning this form,I hereby ce that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EgNo 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#11 remarks section or on the back of this 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'
f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: lid (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@2 0 and 2@/00)
construction to the following:
40
10.Static water level below top of casing:
If water level is above casing,use"+If Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in•)
�j` 24b.For Injection.Wells: In addition to sending the form to the address in 24a
12.Well construction method: fi�1Q/�/ 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) &Wit/ Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit,one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2 Tabs completion of well construction to the1 county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quali
ty ry-Division of Water Resources Revised 2-22-2016