GW1--04643_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: „
1.Well Contractor Information:
Joseph Bailey
la.wATER.ZoNEszvx '. r. k K ._.v; „„lil o. r..;r;Well Contractor Name FROM TO DESCRIPTION
3271-A /.51 ft" trir ft- Aud: biai.re -zone
ft ft.
NC Well Contractor Certification Number
15s,011TLR7CASING(for multkiii divelli OR
K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. i
93 ft. / 25- in. 4' e�, ,4it.
f! I �7 of
,14:INNER.GASII±aoyi.TTauxG(P;Eiaefxne 09ed`-Tti hick, x+v :::kw
2.Well Construction Permit#: le/P- 3/ 3 4( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC, ounty,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 1.T.SG7tEEAte. d s t . . a a,k,,.; r axs',�z,`
FROM TO DIAMETER�� SLOT SIZE THICKNESS MATERIAL����
Agricultural DMunicipal/Public
ft ft. in.
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single)
ft ft in.
Industrial/Commercial DResidential Water Supply(shared) ,
Irrigation FROM TOY c,i ay,..;
MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: o ft 20 ft
Benote Pour /-rs IJ�
Monitoring Recovery ft. ft. �/
Injection Well:
Aquifer Recharge OGroundwater Remediation ft. ft.
Aquifer Storage and Recovery d9+SAAIID/GRAYLL INEIK(MATERefili e),. i' _?.,P-,:,+CEME ' , OD x `)
�y °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology QISubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ';;Zt):iDRILLLNGi..LOG=(iitlach:additions`lsheetv;ifuecev t „�;
Geothermal(Heating/CoolingReturn)) Other(explain under/ #21 Remarks) FROM ft TO� ft D Srj IPIION(color,hardness,soil/rock type,grain size,etc.) w
4.Date Well(s)Completed: Well]D# '/�T V `!tl' I e/-
�f ap 3 v., 0 ft. e0 ft. � syl
5a.Well Loocation: A / T A`$ft. LJr ft. %P4 g_ ^ `' "!.SOr/
Arlo,a d-r Name A f 4reg �//'✓ f di /ti A,(4 I/5- ft. so ft ,k rk fil 6 e /$0
Facility/OwnFacility ID#(if applicable) 2(0 ft !OG ft QQ ar f 5 L
a34 4/lea.ade Coale,�rbvrAidr/7 ��;00 IOU ft. aft" /d..�/ re ftc f/
Physical Ad ss, // and Zip ft. ft V
Co, O')/'S 1— iv 1t: mmuts._ zv x , � , r ,s _ , ,
County Parcel Identification No.(PIN) ` P.+
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ti.
(if well field,one lat/long is sufficient) l� I h �i���
22.Certifi lion: J l
N
W Alec' 1,-, !.tvrt`C^•':fk'�t'4I J '�T,y� R74,2 J
6.Is(are)the well(s)0Permanent or Temporary °st:' s.�r.r$a„
Si,.,.silo. of rtified ell C, ,..ctor Date
By signing this form,1 here,_ 5,that the well(s
d in accord
7.Is this a repair to an existing well: JYes or eko with 15A NCAC 02C.0100 or 15AtNCAC 02C.0200)Well Constructionwas(were) t�ucte Standards and thatance
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:
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:'
a10.S / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths if different(example-3@200'and 2@100) ons c
(ft') For All Wells: Submit this form within 30 days of completion of well
construction to the following:
40
10.Static water level below top of casing:
If water level is above casing,use"+" (ft.) Division of Water Resources,Information Processing Unit,
/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: fl07 fI/ 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) 00 6phi Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection Chlor Tabs 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. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016