GW1--06518_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: I f
Joseph Bailey 14:IWATER201VEs k 'I , , ,, :
Well Contractor Name FROM TO I DESCRI' !ON
3271-A lLf 0 ft. ?4o`Z f i e prv„.1 2.a4e
15 ft. '1 14ft�....'v' e4 f erci it Zane
NC Well Contractor Certification Number 15 O11TER•CASING(for;multi-cased•wells)`OR`LINER:(ifap 7lcable)' '
B.&K Well Drilling Inc FROM TO I DIAMETER THICKNESS MATERIAL
Company Name ft' / / ftl , 6.25 in' SDR 21 PVC
���p d ��a�� :a16 INNERCASINGORTUBING;(`eotbermeliclosed loup z l w ; •
2.Well Construction Permit Ai:: _ FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft• in.
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3.Well Use(check well use): ft. ft: in.
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Water Supply Well: FROM TO �.„jIDIMtETER SLOT �- :.cy-<..!"?
SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. ' in.
DGeothermal(Heating/Cooling Supply) oResidential Water Supply(single) ft. ft. in.
°Industrial/Commercial DResidential Water Supply(shared) s',18¢GRo1JT ^ . , , P r,
0 Irrigation _ FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: -'. --t`'•' , '..\ti i o ft- 20 ft• •Bariod Hope plug Pour /4 alai/12
°Monitoring DRec very' •-/' " ft. ft.'
Injection Well:
I 2023 ft. ft."
°Aquifer Recharge °Ground r emediation
°Aquifdr Storage and Recovery Salini Ba er ^.,:v a•�.:„3 sly; .`19::SAND/GRAVEL°PACK(ifapplicable),,,.:,;:; ,„-; M25,
D tyr ,Sr it FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test DSto°'water DFainagii 1O_i ft. ft
°Experimental Technology °Subsidence Control ft. ft.I
Geothermal(Closed Loop) °Tracer ,z•20'DR11SINGIOG:(attiel ailditio iiisheetsif'riecessery)'s, `.
DGeothermal(Heating/Cooling Return) FROM TO I'' DESCRIPT ON(color,ne ness,soil/rock type,grain size,etc.)
( g/ g01Other(explain under#21 Remarks) 6 It. /� ft.I ��e S i J�
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4.Date Well(s)Completed: 7.1N3 Well ID# /At /35 is' ft. y(ft•i "OW n S.tTe 1/5a.Well Location: 35' ft. .Pco ft.i w/3te q,/'/
J`t,I Ill ic. (re,Wer Aogi564 ipo ) .�Q ft. 100 it ,6 G S(�/r/
Facility/Owner Name Facility lD#(if applicable) 40 ft. 5' ft. ;lip i/ ,1 c./(
I/O W 1 rhae -r GI flitiefM I/€ WC. ?�'/,( PC ft. 07 ft. ,G9%4;Tom,?oc�c`
Physical Ad ss,City,and Zip 6 tL ft
re, ift CO, q4, -lob-ly/;
aunty Parcel Identification No.(PIN) '
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W de,,,...„./
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6.Is(are)the wells))Permanent or °Temporary Si tore o r rtifi d Co ltmci Date
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•signing this form,I hereby sift'that the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or fgllNo with ISA NCAC 02C.0100 on 1 A 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 priovided 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: h/� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /7J P (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:
40. '
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
limiter level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection Wells:1 In addition to sending the form to the address in 24a
Rotary above, also submit one copy'of this form within 30 days of completion of well
12.Well construction method: 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) /,11 Method of test: Air lift 24c.For Water Supply&I 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 1/0 Tabs completion of well constru'cti'n to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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