GW1--04649_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey •a4::wATER'zot s, ,.. _5 i ,{.a.-4-:f ,r.>x a:a-1..r u
L
Well Contractor Name FROM TO DESCRY IO
3271-A !AHD". `Uk n. ki ed Fro 6T,i/j6-i1e
NC Weil Contractor Certification Number j Ail J Mr/I fir/(rre,z �/'
1S'-,QtITER C tSING(fer inulit4ii0vells:ORTANER(fihp"}lcahle):R ,..gg+ `,.r':
B&K Well Drilling Inc FROM TO DIAMETER [THJIICKKNESSSS,/ MATERIAL
ft. O�.,ft G basin VDR eh
Company Name jf
/� (" /� G "161:14,„viis �laortlf'17 m (i eothekinal,elosed iiii = ,, --
List Well Construction Permit#: t..) ROCA j—l7 4�J 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=SGREEI�> 1. ., : ..nz w_ n
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural DMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single) ft ft. in.
0Industrial/Commercial ['Residential Water Supply(shared) s t.18.GROI��"�'`.,?� ,`;tr�.�t,� ..> ,, � x. rx x � �nrs
ri Irrigation
FROM TO MATERIAL ». EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ao t 20 ft
Benote_ _ ^. _ ` r Pour Qp BlJ io0Monitoring DRecovFrrg1; e 17& y9�! ! ft. ft.
Injection Well: - "
1 n2Q23 ft. ft
Aquifer Recharge Groundwat�rl�emidi o
19:S1ND/GRAVELPACK'(itapplkable)r ;.<. ` - x tM:s'.i
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DStol it4at?f'Diaina e("'''''-''`"4(J •a ft. ft.
Experimental Technology 0Subsidence Control ft ft.
Geothermal(Closed Loop) ['Tracer 2Q DRILT,ING I%OCx(attac7:additignitsheetsifneces
Geothermal(Heating/Cooling Return) FROM TO DFSC PTION(color,hardness,soil/rock type,grain size,etc.)
( g/ g Other(explain under#21 Remarks) ft ! ft. R ��/
4.Date Well(s)Completed: •44'�3 Well ID#,���� 1� f� 25 ft Brdh Seri
5a.Well Location: / a6' So y If cow 13r10,14 S 'JyJ n1
ke/d!K Iatkfeet' L 6� sti ft (.S ft. vny i+
Facility/Owner Name Facility ID#(if applicable) L5/ ft- 8O ft Son- add(
33 �Cemp !>�d,�/�di►�f�sd�/k,w424n $0 ft. /�o1Jiift. /_ w �d(
Physical Address,City,and Zip ft. O'! ft /J't►�a
Xreitll G4 ..2VRENIAT2lCsF; s,.tom ..r , r ,bs M-,,, ,•r9t, st
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
N Wf, )
'V-23
6.Is(are)the well(s)JPermanent or Temporary •
r erti Well Con rot Dahis form,I here •certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or jNo CAC 02C.0100 o 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,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: Q� (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'mid 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: r
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) /540 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
Chlor Tabs 1 1/2 Tabs
13b.Disinfection type: Amount: completion of well construction to Ithe 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