GW1--06522_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:
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Joseph Bailey
14.iFVATERIZONES=. ,.;: 3ia• !; c
Well Contractor Name FROM TO DESCRIPTION
. 3271-A /Or. 100 ft. I lard C PTV s?'l✓re ,p�!-�'
ft. ft. I 1
NC Well Contractor Certification Number 15:`.013TER;EASING1f6;initItt estieOvells):OR 31INER.(if>ip yiicableY.; r
B& K Well Drilling Inc FROM �y TOl� DIAMETER THICKNESS MATERIAL
Company Name 0 it /f ft' 6.25 in. SDR21 PVC
16ANNE&CASING:OR:TUBING.(geotheitiriai liiaed.Ioop) -O,....;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State.Variance,etc.) ft. ft. 1, in.
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3.Well Use(check well use): ft. ft. 1. in.
17tst"REEN 4
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS "MATERIAL
Agricultural 01Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) DBResidential Water Supply(single) ft. ft. in.
IJ Industrial/Commercial °Residential Water Supply(shared) 18:GROUTS 5. - ., ..,? ;;'`;
0 Irrigation FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:. 0 ft. 20 fG Bariod Hope plug Pour Ia
°Monitoring DRecovery ft. ft. , d
Injection Well:
®Aquifer Recharge °Groundwater Remediation ft ft.
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419/SAND/GRAVEL'PACICpfapl►lieatile) ,x;.. , ...f
DAquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft. ;
°Geothermal(Closed Loop) °Tracer :a2OORILLING1.10G(attached"dition'af"sliiiblfnecesseri .
Geothermal(Heating/Cooling Return) FROM To DEscR oN(color,hardness,solUrock type,grate size etc.)
( S/ g Other(explain under#21 Remarks) ft. // ft. Real GJ�-/
4.Date Well(s)Completed: 1-aO't 3 Well ID# ?1)/.3g. ?t sent. 4d ft. )'�,a r/ 5 40.1
5a.Well Location: 140 ft. /00 ft. iGtairir/Aere
• edJ
PO ii0 C L T I ooft. /go ft. ^
Facility/Owner Name ,� �j �y Facility ID#(if applicable) i d°ft. /,3 ft. .4 e,j sO //(s/� we
l fa �l f 1Olt/116 07J?�, �/etiv ix e 1vc,: 64 13�ft. ` 0 ft. 4er 77�W gtrz
Physical Addr ss,City,and Zip I�� ft. 9 a ft. . Rock
�f eft GQ, (.j4 9 o !/Ot_(: /%/ 21:"REMARKS t.. Y� � sx.s....r t; H-.,L.;
County ..
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 0 L T 4 2n23
(if well field,one lat/long is sufficient) 22.Cer' Catio I s-• .
i yr ,...e.^,.il (�f ^tiai•'�;�;�(,�r'{ •
N W ~Dl.oVvl• .OG 9 !S 't
6.Is(are)the well(s)OPermanent or ElTemporary nature Certi red Well Con etor Date
y sign'g this form,I hereb certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or EgNo with 15A NCAC 02C.0100 o 1SA 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:
/!�^ J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: and
(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@20 and 2@100) construction to the following:
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10.Static water level below top of casing:40 (ft.) Division of Watdr'
Resources,Information Processing Unit,
If water level is above casing,use••+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 I/$ (in.) ; 24b.For Injection Wells:C 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 followin+
ry(i.e.auger,rota ,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:j 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air lift 24c.For Water Supply&Infection iection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction 1 1/0 Tabs ction 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