GW1--06542_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I.
1.Well Contractor Information:
1 1
Joseph Bailey .14::WATER zoNEs,. .. .:t: _ , ,r
Well Contractor Name FROM TO DESCRIPTION
3271-A 1( ft' ? 6, ft. SI/os'el Prt..�%rrz awe
ft. I ft.
NC Well Contractor Certification Number
d5IO1TTERCASING(fi multi-casedweRS ORILINER ffiii liable) .i it l
B&K Well Drilling Inc FROM TO DIAMETER ' THICKNESS ' MATERIAL
d�
0 ft li5 ft
6 25 I in' SDR 21 PVC •
Company Name
Cra ` :16i-INNER CASING:OR TThBING'(ieothermalclosed-loop).` ,.s;,T ,+z:
2.Well Construction Permit#: `° ' a7 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: <:1tiiSCREEN,w•'; _ .. : ,. . .; 1:! . ..<, .....
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural DMunicipal/Public ft. it. , in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ' in.
jIndustria1fCommercial OResidential Water Supply(shared) ,18 rGROIIT
NIrrigation FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply 1 Well: ft ft 0 20 Banod Hope plug Pour
°Monitoring DRecovery ft. ft
Injection Well: ft. ft.
['Aquifer Recharge OGroundwater Remediation
Auifer Storage and Recoveryni '19:SAND/GRAVEL,PACK(iifapplicable �
)a _ �",V , , I ,
tI g Sali ty Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage ft. ft. ,
Experimental Technology ' QSubsidence Control ft. ft.
O Geothermal(Closed Loop) OTracer E20:DRILLING.LOG-(attaehailditiouaisheetsif riiiiiiiiiiiiiMiW,I.IIIIIMat:IAIM.WRIIA
Geothermal(Heating/Cooling Return) FROM TO DESCRI 'ION(color,hardness,soil/rack type,grain size,etc.)
( gl g DOther(explain under#21 Remarks) I
® ft ft. Red �Q` /
4.Date Well(s)Completed: c'/a-,2 3 Well ID# 5/ ft. /ft. �� �,,,tel ,3
5a.Well Location: 1 6."ft. Ss' ft. 6-ire)r,IrvApt 5oJv$dl
r r4✓/S /hO ill 5 3( ft. p ft Ira Sefirr?get//
Facility/Ownerit Name �B }. Facility ID#(if applicable)
yin if(ft*
I10t-4L i e /2a.11
4Oa1! I/rl o]r Oq R s e . l6��didt �R+4 ffa) ft. J ft. .`.` --,,
Physical Address,City,and Zip I ft. ft I, r.L.kj,t V.•' i )
�cb��� ��i 21 REMARKS . - ._ ', . , ,„ i__
County Parcel Identification No.(PIN)
UL i 1 v 2023
Ins,.-rrr.e'-', ...7-C7• !.._
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r•`�.-. .,;s:,,5 ,,,,,:1
(if well field,one lat/long is sufficient) 22.Certific lion: / I, I%CV:3OG
N W h //y,. __
6.Is(are)the well(s)0Permanent or Temporary of rtified' II Cont. tor; ate
y signing t is form,I here.•Certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or inNo with ISA NCAC 02C.0100 o /SA 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.•'ovided tb the well ownen
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: SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: a (ft.) 24a. For All Wells: Submit this fort within 30 days of completion of well
For multiple wells list all depths?I-different(example-3 200'an I00) construction to the following:
I
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 Injection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of tliis,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
A,�,� Air lift
13a.Yield(gpm) Y,,�/� Method of test: 24c.For Water Supply&Iniectiori 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 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