GW1--04647_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 7,14swATERzjNEs .mu n ,
Well Contractor Name FROM TO DESCRIPTION
3271-A /SO : l,D, ft' idle
ft. ft. V
NC Well Contractor Certification Number
B&K Well DrillingInc RICASTING;(forntttlt vasiiiiik sTO Hi1LKNESifapilcali1e) ^;A
FROM TO DIAMETER THICKNESS M ERIAL
Company Name /� 3 0 ft. 1�' ft i
G ar In.
n SOR a
`/�s ,/1' /_ 16 JNNER`CASI€lYG'OR'T1)SING:j eothermat etosea=tapys , ��•,///���1000..•. ,,-9P
2.Well Construction Permit#: 4/P (0 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: 1.17:SCREEN U-� �,..w �. ... .r�. ,s .3.�1 _ ,.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .xx
Agricultural °Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single)
ft ft. m
Industrial/Commercial °Residential Water Supply(shared)
Irrigation1131' _ _. # ,
\
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
~'
Non-Water Supply Well: tl�-,ei,..�a �L /J {4 ,#1
Luiy r,-..'.LL.r p ft. 20 ft. Benote Pour
Monitoring Recove ft. ft.
Injection Well: j
Aquifer Recharge Ia I• e A. 2O n 3 ft. ft,
q g E3Groun water Remediation
Aquifer Storage and Recovery oviAityiB�iticl.�r4 ���7• r (:�� '"19 SAND/G12A(tEI PACIC(i£aPPbie)_ . : d :,. y 3. s
FROM TO MATERIAL EMPLACEMENT METHOD
my,24%::4° -aAquifer Test 0Stormwater4OtAI2e
ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer
:20;I)1211.LINGIs'GfG,(alto"cfiaddttiori8lsheets:3tnecessatV��.r., ,._.;,„, `a ;,.,, ;',r:;
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCR ION(rotor,hardness soil/rock type grain size etc.)
A rf `- 6 ft* /O ft- f sad
4.Date Well(s)Completed: 5////p�. Well ID#,.SCC/ /h.1i/y / ft. ��ft, f�{��Jn Q4
5a.Well Location: 6-ft. / ft. /7e//riv 50,r
1r7 7 4 tl akr GAS-ft. Kr ft- .T rsy ,obi Gc An/
Facciility/OwnerNa ofJ �f J_FacilityID#(if aapplicable) (� irft. /, ' ft. �!/5�Q4n ���,,
J ic /rnwedie j Weer e6140G/gid�it/ /e+�.7 t. P 4Ij ft. //'r/i k 7 (�/ i3
Physical Address,City,an Zip ! B lerft /`rfr ie Roc
.CreaeII Ca, yua9- !9- f(%5' -i1 REIVIARKs. A .,_ ,,. -A.:.fit ts x4,sr.. :�:
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
6.Is(are)the well(s)JPermanent or Temporary tore of erne ell Contract OAT_
By signing this form,I hereby c ify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fYes or EiNo with 1.5.4 NCAC 02C.0100 or I5A 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:
/ r SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: 4J / (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@200'and 2@1001
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 Iniection 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: Rant/ 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) 3o f Method of test: Airlift 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs I tlz Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction toi the county health department of the county
where constructed. 1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016