GW1--04648_Well Construction - GW1_20230714

'r.,0 1.6"'t Pnnt Form
� a� �3 S �3.. .
WELL CONSTRUCTION RECORD (GW-1) " For nternal Use Only: .
1.Well Contractor Information:
Joseph Bailey •14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
3271-A 1 A, ft. ,,�` ft s / pro,c 7 1 ..2o-
NC Well Contractor Certification Number RI®ft. y� /3". ,��t�c Fi G e e,
15,OUTER CASLNG(for mtilti=casettOrells)DRLINER(if aii lkable}
B & K Well Drilling Inc n. FROM TO DIAMETER THICKNESS MATERIAL
Company Name (,j 1�1 1" .24 2.3 Z w 71 4 C, ft. 40. ft. / .I c in. 50 r2, At
����� 16.INNER:CASING OR TUCBIING::(geothermal closed-loop) -..
2.Well Construction Permit#: rt�t% FROM TO DIAMETER THICKNESS MATER L
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. /_ D ft. y in. !�- y0 47 4
3.Well Use(check well use): b ft. lD ft. j in:" �]
Water Supply Well:
17.SCREEN.,
_FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) •18'GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: f^'e�; f -'�i• 20 ft• Benote Pour
t P
•
Monitoring Recovery -..%-ft. ft.
Injection Well:
•Itr Li 4 r 2 123 ft. ft.
Aquifer Recharge Groundwater Remedi
19.SAND/GRAVEL PACK(if applicable)'•<t: .- 'l Aquifer Storage and Recovery Salinity Barrier r.r:al.r.Th l7 f,�ra, 1 RONI tl;;i: TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ; Cf`r50 r ft. ft.
Experimental Technology 01Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING=LOG'(attach'addittonaisheets if necessary) . •:a
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
/� r 0 ft. f/ ft. Rej 54
),
4.Date Well(s)Completed: V/ .//3 Well ID# V/57 • 9/ft. tg`�a ft. i3 f 7
5a.Well Location: 120 ft. 30 ft. ro-,.may 5e, I 7a
IA el; 't �1 td� ey O ft. ft. 3 o �'" (4 c/( VK /
Facility/Owner Name Facility ID#(if applicable) 1 ft. `r t. �i!y 'ie7r� 6
3r 13 4.reS t 2®v�m,/V 1vi1/er/Ilt;t 7I®) J v ft. �l �fA ft. 6✓
Physical� Address,ACity,and Zip / / /`' J1 /� ft. ft.
Tittle// 4 . '7 4"�t-i 1 !/ . 21.RENIARKs / :: -..9 ur .F :. 4..;.-
County Parcel Identification No.(PIN) /n:1 2 v T2 11 5r{ & r ••-, e2 1 t4,s f"aw i r eh
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L3YO 4. .A, ITV,r'{ 0'la.il.2'3
(if well field,one lat/long is sufficient) 22.Cert' ation:
N W I r . 05/26.Is(are)the well(s)0Permanent or DTemporary Si turc ocrti t ell Con ctor Da
y signing this form.1 her certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: fYes or 10No with ISA NCAC 02C.0100 or 15.4 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:
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
ry
9.Total well depth below land surface: 2O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd/erent(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: 1�6 � 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) 1/4„idok Airlift Method of test: 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: 1 1l2 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