GW1--08118_Well Construction - GW1_20231215

h l �3 rn Rcit; ot
WELL CONSTRUCTION RECORD(GW-1) For Internal se Onfy',:�'
1.Well Contractor Information: I • j
I 1 Joseph Bailey.
,,14..WATEIt°Zt?NFS, #�
Well Contractor Name FROM TO 1 DESCRIPTION
_
3271-A 360ft" 3G •I t E. f' ,/eife
ft. ft.
NC Well Contractor Certification Number A5 OUTER CASING(for tritiltl-cased welts):O1tiLINEIC(if:itp ltcable);"" _,• ',k ;`.
B&K Well Drilling Inc • FROM TO 1 DIAMETER THICKNESS MATERIAL
0 it )1
6.25 1° SDR21 PVC
Company Name xd
� l ;46 f NNERICASING.OTkTUBING(geotherrttel:citised loop)_. „. y ';., `
2.Well Construction Permit#: 1)0 9 r 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.
17
Water Supply Well: 'SCREEN,..;l.' , .:.. ,.. !.,..:. . . ; 'I c;
pp y FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. . in.
DGeothennal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. ' in.
DIndustrial/Commercial ®Residential Water Supply(shared) 38;.GROiFT.., :s: ,y•._,T r...;
',Irrigation FROM TO 1 MATERIAL u w EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: o ft• 20 ft•, Bariod Hope plug Pour /3 liv S 1►r
Monitoring D Recovery ft. ft.'
Injection Well: ft. ft.
°Aquifer Recharge °Groundwater Remediation •
.195'SAND/GRAVELPACKlifappl1 bie) „_: g% , ..;.' ,i..::.: ..g. _,:a+ :
°Aquifer Storage and:Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD•
Aquifer Test ElStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer .,20 D1 ILISIVG'1.10(ntticl eaditioiial'sheets'ifaecPssary) '.c,.,„.T; ._'...,
°Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM I To I DESCRI ION(color,hardness,soil/rock type,grain size,etc.)
I ft. f�ft." �75 i?l
4.Date Well(s)Completed: 1�o10/a V9e�l ID ���I�� ft. 3(ft.r ��ro �011 .
5a.Well Location: / 3 ft. Lc': ✓e�/ek14�477 i on
/1/0,h ,d�5 1e[�-, #11 te(ft. 9G ft., trey /3 ro— 5 / c#r P I
Facility/Owner Na a Facility ID#(if applicable) 9 0 ft. / ®�', m /' /?cc
® (, ,//_4 i e i?41_ 0144.01k,/VG_ a'?di 10..( y 00� 6oi'�h >? k
Physical Address,City,and Zip ft. ft. 11
I ce.,' h
I7e6 nerd*, fG_ //3r/G? . 1REMARxs . vt �; > qa - �-
County Parcel Identification No.(PIN) DECY � U* 5' 202 3
,,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ��_; ._ i✓
22.Certif ation: Inf3i r':•,^ .D . ,Fl
N W D, a t:. „)..ia
6.Is(are)the well(s)0Permanent or E3 Temporary Sign ure of-reified a Contractor' Datc
B signing this form,I hereby.-r jy that the well(s)was(were)constructed in accordance.
7.Is this a repair to an existing well: ®Yes or EnNo th 15A NCAC 02C.0100 or I NCAC 02C.0200 Well Construction Standards and that d'
If this is a repair,fill out known well construction information and explain the nature of the copy of this record hat 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: SUBMITTAL INSTRUCTIONS " '
9.Total well depth below land surface: 'o6--` (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 a•l00') 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"+" 1617 Mail`Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (in.) 24b.For Injection 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.) r
Division of Water Resources,Underground Injection Control Program, ..
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Air lift pp Injection
�� Method of test: _ 24c.For Water Su Iv& Wells: In addition to sendingthe 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 the county health department of the county
where constructed. +I
Form GW-1 North Carolina Department of Environmental Quality-Division of W at+r Resources Revised 2-22-2016