GW1--04645_Well Construction - GW1_20230714

' Print;Form M
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3271-A J 6 yft. J 9.ft. Lt C r'YYrf`/ .7lre
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING.(for multi-cased wells)ORLINER(if-ap licable) �';`'.'
B &K Well Drilling Inc FROM ft. T6? ft. DIAMETER in THICKNESS Qv , M ERI�L
Company Name �✓j��G.
e_ _A ���� Q�//� 16.INNER CASING OR TUBING(geothermal closed-loop); ,
2.Well Construction Permit#: .51441I j 7 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:SCREEN :__ .;.` ,s.::: :` ".
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
.l Agricultural E3Municipal/Public ft. ft. in.
$Geothermal(Heating/Cooling Supply) r@Residential Water Supply(single) ft. ft. - in.
illi Industrial/Commercial [jResidential Water Supply(shared) 18,'GROIJT
v
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. Benote Pour Q)vs H.
$•Monitoring E3Recovery ft. ft.
Injection Well:
ft. ft.
jai Aquifer Recharge E3Groundwater Remediation
19.-SAND/GRAVEL PACK(if applicable) `,
$1 Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
all Aquifer Test IDStormwater Drainage ft. ft.
*Experimental Technology E3 Subsidence Control ft. ft.
lg Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach addltionai sheets if necessary)'i.:.
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
alGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) d ft. /a ft. /�e Sal
l
4.Date Well(s)Completed: seal?3 Well ID# LOT-4/ / ft. a ft. deo.�o f01 T
5a.�Wjell Location: 9I �r / / � ,�! � ft. 10 ft. O/f Wn C$ I
1k/m 1�e i5JLC 1401 Iwbof6L , 1/0 ft. ,,�` ft. Tematt time'? j4•1��a4y
Facility/Owner Name Facility ID# £applicable) ft. 7 i) ft. SoF'T ccr
/3° f/ar�dor '7t Rdi. /s1oons ///e,AedolD 50 ft. 46 ft. ,,7 ®C/(
Physical Ad ss,City,an Zip ( ft. ft.
"itJe// G� ��a� 1Q41Q 21.REMARKS ' ' ^
L N'cm @v+'I--i V i1. 2,
County Parcel Identification No.(PIN) n?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JUL 1 � ZQZ
(if well field,one lat/long is sufficient) 22.Certification: j
s
'� / InIV\7f'".tVi f',it i�r.^...•SJ.'fe>:''n '0'.'R
N W _di% ,, 0/ G``\TI 4`,:�� . 1,p7
6.Is(are)the well(s) Permanent or OTemporary a ature of edified Well Cont rctor Dat
y signing this form,1 her.by certifil that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or EINo with 15A NCAC 02C.0100. 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(his 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:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 0✓ (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdifferent(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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0� 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) 01®VLSf", Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: t 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 Revised 2-22-2016