GW1--04569_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey a4:wAxER`zON>rs t
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Well Contractor Name FROM TO ��
DESCRIPTION ti
3271-A /gifft- /9� ft• fM�/ nei7 rtZ
NC Well Contractor Certification Number aOyft. a,rt. Frf./•'��o +
15 OUTERiCAASING(fora ultacased�wadis))OIt G,''?7lNZEE'.(lta.. ltcable) c o;„ 4 M
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MAT RL4L
Company Name 0 ft. /0�y 1 ft. C/.� rn sf4 a;
";16:11%1NEWPACIN ORTOBINGAgeotherrna ttatrie1461i) ' :: ,MR 4
2.Well Construction Permit#: C 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,_.; __._.. _ ._:, �, V ,g
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
l DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft ft in.
Industrial/Commercial DResidential Water Supply(shared)
7.18:GROUT ? ,.te., tt, a'fr.,. ." ., it
Irrigation FROM TO MATERIAL � EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Benote Pour J f'$
Monitoring Recovery ft. ft. 1t/V
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation ; Z. s a a t. ,
Aquifer Storage and Recovery Salinity Barrier i 19»SAND/GRIMEIAoetwiTER able).,.,.u,M g„M,�, u ,,
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft JUL . ' LULJ
Experimental Technology oSubsidence Control ft
ft. lf1(3i r i ^.it g IJ C
Geothermal(Closed Loop) Tracer • 20"z=DR1I;LING LOG'(aaattrailili'onai=:sheetaiEfcrcassacy) 1
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft �/ ft FROM TO DESCRIPTI N(color,hardness,soil/rocksoil/rock type grain size*etc)
/ 0 /( St7,-/
4.Date Well(s)Completed: 4/a a 3 Well ID# L G . . q ft. a aft- `1„'- lJrtfivn 5 iJ 0
5a.Well Location: /J D ft.ft. J f. /'//d4,"gcait/n 5e/11.4 5o'/
/Al/11fN4.7i me5 �'#`// ' Ili . 'f /terSit1 ,iS'4 i;-1
Facility/Owner Name Facility ID#(if applicable) ft. ft
�/� ,S��rr/�,'( 0 14 C ,!/ 7S 9� G�Gc sv�/by
SS' !60 R . 5 /as h!/V • gc ft. // .1 ft. � Grey �j•L,'(
Physical Address,City,and Zip PVie)
//'1 ft 'mot/ 6mi/1; Ro 4r
Roc.* Ca. ki- /43 / VNIAltIC iw`J__ . a s r II w
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) 22.Certific 'on:
N W
6.Is(are)the well(s)OPermanent or OTemporary Si of C ified I Contract 1- *5—
5 Z
signing this form,1 hereby t fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or JNo with I5A 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:'
�� f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 (ft) 24a. For MI 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
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: ?Q 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) ita 61/'I Method of test: Airlift 24c.For Water Supply&Insiection,Wells: In addition to sending the form to
Chlor Tabs the addresses) 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 the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016
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