GW1--06523_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I ,
1.Well Contractor Information: [ '
'Joseph Bailey
.d4 V1'ATERvZUNFS l:`1= _.
Well Contractor Name FROM TO DESCRIPTION
3271-A /tilt' / 9 ft. ,kG/f sFar-cry�d ee
NC Well Contractor Certification Number 0f t3 3 �fr � �� r v/� ZaQ
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=IS:;QUTERCASING{fvratalttceseiltvells)ORLINERIKa-ticaNle),
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft t 6j ft. 6.25 I in' SDR 21 PVC
Company Name �J B+
`n y @ .16INNERCASING`OLTUBING'(geotheriiiireiosed?]tipp) ai „..
2.Well Construction Permit#: IJf'0 '0/71 33// 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: ,A7'SCREEN s .i;,;. ..., i .x .r :< .i j. -, .El
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL T,
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. In. .
[]IndustriaVCommercial 1
Residential Water Supply(shared) ,8,GROUT ; .,'
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT •
Non-Water Supply Well: o ft. 20 ft• Bariod Hope plug."^1 rout
0Monitoring 0Recovery ft. ft. q L.(a a Cr (y9i''"
Injection Well:
Aquifer Recharge Groundwater Remcdiation ft. ft. n C T ! ^^
` l' `� /}
Aquifer Storage and Recovery Salini Barrier ..19i(SANDIGRAVEI&PACK(if applcable) � ',,Ltl t y=, i i'I
tY FROM TO MATERIAL, EMPLACEMENTgq METHOD
MATERIAL" ;
.Iftihi:.11 t:' "S,F,yy.r r Aquifer Test Stormwater Drainage ft. ft ( ;`' I�l L
Experimental Technology Subsidence Control ft. ft. ``'a
Geothermal(Closed Loop) OTracer 20 DRILL`INGLOG(attaehadditioust'stieets`ffnecessaiy)i ,,,,. lia
©Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION etaior,hardness,soil/rock type grain size,etc.)
�` /1 ft. / f/ft. Reif (ei 1
4.Date Well(s)Completed: 7 /5 23 Well ID# 42 I „(ft. y s..s• /{�!�(�4/1 sof
5a.Well Location: �,r ft• AC /!<Ara it Iamiss kfres./.7sgifrfri f
fri
y/Owner Name Facility ID#(if applicable) ('0 ft. 9
- ft- ,cs, ',i,(C
)24, a�lleM5741;foilect#6 264 4) 9(ft. 44 -ft. � � /70 6,4
Physical A dress,City,and Zip ft. ft
eoldi n 022: 0.42m
County Parcel Identification No.(PIN) ,
I.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific lion:
N W S I -01
6.Is(are)the well(s)JPermanent or Temporary tore of rtificd I Co trac Date
y signing t is form,I hereby lily that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or rigNo with I5A NCAC 02C.0100 or .)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 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 alsoiattach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 945'.I (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@.200'chid 2@l00') construction to the following:
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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 Iniection Wells: 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:
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)
40"-"' Method of test: Air lift 24c.For Water Supply&Iniection!Wells: In addition to sending the form to
Chlor Tabs 1 1/0 Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. i
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016