GW1--06528_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
',
1.Well Contractor Information:
Joseph Bailey r—,. ,T r "• '14 wATER'zDNFs.s , w�,° k Yrr_: .v�•,:�S t rx x., �_ _43s,' `._"�
•, - - FROM TO DESCRIPTION
Well Contractor Name . e�-1/4,"1.,..;. �, �, L.,: ' �^
3271-A /$.ft Art ft. _ Si4 so// A:rf67/I� ,a/te
OCT 1 2023 ft. ft. i
NC Well Contractor Certification Number 1 rS OUTER CASIrI!IG(f'ot°inaltL=caseithia.cxtaRII. }{ig'`" lleabl"e}' `",',- :='
1Rsurmi.'%:�`.'.l P17,:'- ttvli' Jrg L FROM TO DIAMETER THICKNESS MATERIAL
Ra
B&K Well Drilling Inc ",� :a 1•,,
�a__d 0 ft //f ft 6.25 I to• SDR21 PVC
Company Name /� l ynQ��, t466:'>FNNTsR_CA;.+(/NVG;OIi:'CUB1rI {fe'iithernt'a2:etaSerl.,laop}�SR2 iz �t '.a".—=
2.Well Construction Permit#:YYe/i �a //-aoaa- I vV G a/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft• in.
Water Supply Well: m .rM .:<'""4.- : -� :r " „Kt
pp Y FROME TO�4j ��DIAMETER- SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipa]Public ft ft. in.
®Geothermal(Heating/Cooling Supply) raResidential Water Supply(single) ft ft. in.
Dindustrial/Commercial DResidential Water Supply(shared) xa$`6ROt7 a r w v' , , 'k r -: , i
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Ballad Hope plug Pour /o BUT
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
ID Aquifer Recharge ()Groundwater Remediation
19.:SAND/GRM .E,PAt ;(ifiap} able) .Ph a3 :r ..w.„„ 4 ,..._.t
)Aquifer Storage and Recovery Salinity Barrier FROM : TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft. '
Experimental Technology DSubsidence Control ft. ft. '
Geothermal(Closed Loop) °Tracer -.ZD DRIELII<I >T (attar'fiad`ditian"asheets Eueeessac=)rif f M"1= ,` .
FROM TO DESCRI ION(color,hardness,soil/rock type,grain size,etc.)
DGeothermal:(Heating/Cooling Return) riOther(explain under#21 Remarks) ,t
G ft /6 ft So
r i
9 4.Date Well(s)Completed: '?3 Well ID#hir, /d ft. aJ ft. 1le
71Llr7 54/q
5a.Well Location: a eft. sir ft. /5h !rifi,g 5S0P/Sei
9 0 k i i/cf t ,r3"f t J/1/%t4 u//v,✓�sf4/.Sar I
,�rwnerName L07�. /Q4G ll f�SC��/_ 5.7c.5. 1)a ft se/Argo
Facility/Owner Name Facility ID ,f applicable) bey
Physical Address,City,and Zip I , �/` h ft. ft.
TEW40 4417 ijkl f a/i ^;21 srmutsk z } -,^oaf :-7V aaaa5 .,.itA >. ;'
County Parcel Identification No.(PIN) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
_ 7.2.3_
N W tom/ r
6.Is(are)the well(s)JPermanent or Temporary Si of Ce led ell Contracts Dace
signing this form,I hereby certi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or giNo with ISA NCAC 02C.0100 or ISA 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 sto 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: SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: 61 ! (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 00'and 2@I00') construction to the following: 1
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 Infection 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: 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 Cent i r,Raleigh,NC 27699-1636
13a.Yield(gpm) /ye/ Method of test: Air lift
L 24c.For Water Supply&Injection I Wells: In addition to sending the form to
• the address(es) above, also submit!one copy of this form within 30 days of
Chlor Tabs 1 1/0 Tabs
13b.Disinfection type: Amount: completion of well construction to h county health department of the county
P
ii
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016
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