GW1--04652_Well Construction - GW1_20230714

' Pfint Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14:wATERzovEs
Well Contractor Name FROM TO DESCRIP'ION
3271-A /60 ft. 1 da ft. /wed I-mivsez
ft. ft.
NC Well Contractor Certification Number
`,15:•oUTER'CASING(for.moth-case'd.wells)MOANER'014 livable)
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL,. -
29 ft. 0 ft. ° in. C/� �/�
Company Name �. t!!/R�1 ® 6'd
®/ 2 :16.INNER C ING OR TUBING:(geothermal'elosed=loop)
2.Well Construction Permit#:14/1 p/ -®,�-#;4142W' -/ LILT FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction per rrts(i.e.U/G County,State, variance,etc.) ft. s ft. oo in.
61 0' icy #0 is
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.5CREEN
,
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FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. in.
Industrial/Commercial ®IResidential Water Supply(shared) iS:-GROUT .:
Irrigation �-`^' - ''.."1: .`.-'• y't,.;r'.' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Nit_i<,,,,r 9,....r, tla ;._.t..' 0 ft. 20 ft. Benote Pour 75.
eV(
Monitoring Recovery ft*, , Q
Injection Well: jl ji 1 I_ 2N'LJ �,) ft' 4r7Z �o •rc DHSS
ft. ft. v
Aquifer Recharge rouo1watcr Rcmediation
-rr' ^f1 �r -, � �'�`� 19'.SAND/GRAVEL'PACK(if.applicable) = ',:: _.;1
Aquifer Storage afli iebo2G`r�(1 V.;fit Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
Aquifer Test 1I�, 0 Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20i:DRILLING rLOG:(attnehedditiorinisheetslfnecessary) ,
Geothermal(Heating/Cooling FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
( g/ g Retum) Other(explain under#21 Remarks) 6ft. `6 ft. (?�, So,iJ
oo -� / i
4.Date Well(s)Completed: ,7,Z� 3 Well ID# /6)/ A /G ft. c ft. i�r,��c� 7
5a.Well Location: j, R�ft. ft. f°//.4.,
.'&.wA S� V 5 ) /
/Ve 1/6/�leLa. /fame Sift. /_ft. St _ _2ttJ -S/4-er) / 7`ryr/�zit'J
Facility/Ownerit Name Facility ID#(if applicable)pl 4� ft. 1).r ft. attetilJedet
d�9 9 !\/3T//. s% f -q/ /� 6k � 5 rft. f5 �rt. e ra-g �rIoot
Physical Address,City,and Zip /6 ft. ft.
CIA 44 q O. /A b/66R 0?44 21 REb//ARKS �..,, /��]]®
County Parcel Identification No.(PIN) well ptidgr1 a��a/ef� /7rl"l J f ,��‘�9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '?k f3I /�i'lc*:2 '- O O71 1)
(if well field,one lat/long is sufficient) 22.Certification: (!
N W 4�
6.Is(are)the well(s)0Permanent or Temporary Si tuc o fied'W on :tor Dat
B signing tINNX}}"s form,I hereby cc, 'y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or IONo with 15A NCAC 02C.0100 or 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:'
ry t
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �f t�� (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@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
y� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: .oP4gy 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) /0 6PI 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: 1 1l2 Tabs completion of well construction to Ithe 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