GW1--06520_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD GW_1 ' t' rr
For Internal Use Only: ' iif:, �€
i
1.Well Contractor Information: I i
Joseph Bailey :11. `
6itATEti'zt)IVES „W rP '; rs ' a
Well Contractor Name FROM TO
DESCRIPTION
3271-A / Oft' /9d-ft- .SMf// ICrsor�tC
NC Well Contractor Certification Number 0 n
B &K Well Drilling Inc `is;°ou seAsING(farilmC- w -}oao: n n13fg T r
FROM TO I DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 90
ft 6 25 m
I` SDR 21 PVC
2.Well Construction Permit#: do a 3— a y6 2.3 w16-ANI ER_C YS/NOXIKrA j.BJNG(g¢otttermaliiiii d-tttoli .
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft i in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: AliseREEN ✓" `a .k ,, re- 3 - is .. 14. t , ' ;a a
o
Agricultural °MunicipallPublic FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Supply) ft ft in.
Geothermal
(Heating/Cooling pp y) Residential Water Supply(single)
°IndustriaUCommercial ft, ft. in.
Residential Water Supply(shared)
Irrigation 58. ROIJ7 s: s y u $a s
.., .,
Non-Water Supply Well: ' • 0R M TO MATERIALo EMPLACEMENT METHOD AMOUNT
f, . ' I.�-. 1 ,0 ft. 20 ft. /y J
Monitoring ()Recovery"' �'"P l' `' �t �"" " Bariod Hope plug Pour (((///
Injection Well: ft. ft
e(�rrT '• OZ3 ft. ft.
Aquifer Recharge
°Groundwati f Remediation�
Aquifer Storage and Recovery Salinit� , /GRA`S?EL':PAGK'Ifapplicable` Vt r 'o
p'$ ner...1 ;3r,•�$•:t47,4(,3 t•1,-FROM TO C ,. .:. ;
°Aquifer Test ,,� -, ._ MATERIAL EMPLACEMENT METHOD
°StormwaterDraitrage•��%-- ft. ft.
°Experimental Technology Subsidence Control
ft. ft. ''
Geothermal(Closed Loop) Tracer
20aD tlLLtiWGGt1GOIYachadillhatwtsheetififaie 1, ,r �'=
Geothermal(Heating/CoolingReturn) FROM TO oc r size,etc.
Other(explain under#21 Remarks) DESCRIPTION(color,hardness,soiUrock type,grain etc)
�+ I) ftM ft. R�54i)
4.Date Well(s)Completed: q//f e/3 Well ID#ZQ7,$G
/ ft.
Sa.Well Location: //"� !� � / �Or/
i�ellL r dGK Vatir (�' killdeer/eer/ act. q1) f` /lca 4y?r •e 501/
ail / Hgr'reit i!O f. &Jr% i.i4 ,3r s 50?/
Facility/Owner Name Facility ID#(if applicable) /S ft. g ft.
// 4sr� �4�1< 6r „Plates v,1/ j/C. ire) ft /C tq eFl -/?o ���"`"°�
s
Physical Ad ss,City,and Zip a gil /Q`, ft �/� f.tZI1-
v (/ `1d�20�
'% 2" F^ wTri - u RL.
ounty .. 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 I N '
L
6.Is(are)the well(s)JPermanent or Temporary i/271
of erci e. oil Con. tor Dat
signin this form,1 hereby cent( that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or ElNo ith 1SA 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:
litic/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths rfdifferent(example-3@200'and 2@/00) 0.0 24a. For All Wells: Submit this form within 30 days of completion of well
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"+'
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Injection Wells: In addition to sending the form to the address in.24a
12.Well construction method: Rotary above,also submit one copy of this form'within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: - Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) • L r, Method of test:Air lift 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabsthe address(es) above, also submit one!copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/0 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