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Home My WebLink AboutGW1--08119_Well Construction - GW1_20231215 94 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Onl y: I: `a ` ,311.Well Contractor Information: Joseph Bailey ! 443v*EER'161 l 7 zx im a z g aim __ , Well Contractor Name FROM TO DESCRIPTION ._ - 3271-A atom a9q fr. "tdli Pmcrvse-2I4 NC Well Contractor Certification Number ft ft. I s 1tialT1x1 I2IC;ASINGx(frirdnttCh cu iiii*l iint,I 1i�R(if 1icalile) w i"B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL Company Name 0% i i 2 0 ft• 16 25 in' SDR 21 PVC Q (� ft / /5/ raNnR.G&SI IWUIC-TGB AGTitio hernial THICKNESS x "L- ')r:2.Well Construction Permit#: Ob 3 T FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) a' ft. /a�ft. 4 I" in. he- 3.Well Use(check well use): ft. ft, 7 in. �`j 0 Water Supply Well: 137.4CREEI+t,,, E,,xWMIEWOM - �Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Municipal/Public ft ft. in. °Geothermal(Heating/Cooling Supply) EtResidential Water Supply(single) ft ft in. DIndustrial/Commercial QResidential Water Supply(shared) D Irrigation s Ggowto . i r �., t , .'. ,O wva. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft 20 ft. ifaysM Bariod Hope plug Pour Monitorin Injection Well: Recovery b ft- I^/ ft. Panty + �'X roil, � , Aquifer Recharge ft aJ ft. f/o /' d ?4/l5 i0o,7,4 q g Groundwater Remediation Aquifer Storage and Recovery Salinity Barrier t19'B /G rPA CiSPRl ble) ,„ ,a 11 FROM TO MATERIAL EMPLACEMENT METHOD 0Aquifer Test DStonnwater Drainage ft. ft Experimental Technology 0 Subsidence Control ft. ft • °Geothermal(Closed Loop) °Tracer 'rl'2Ii DI1D '11 Gi)-rpGs{atfac ra" r ttto is sheen fiiike °Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color hardness,soiUrock type,grain size,etc.) 0,3 �o ft. ft. ® P4.Date Well(s)Completed:1/ Well ID# 4brfy 1 e I JO% /rft 4oft• groin56iI 5a.Well Location: 110 ft. Q O ft- /w�y 1 Fyn C/a�e _1�/r l/?f;k# 38 • $0 ft 10/e Jft' //o'k'Jeri $4e//e' c/ Facility/Owner Nam ��y /� Facility I/D�##(if applicable) ' 1 13"ft 3/JO ft. ! f2)ikw Rock S3)/ ,l e00 CAarkif�VG. avwf 13, ft. Ocft. 401 I?a4A Physical A/d'dress,City,it and Zip qd ft ft. ine County J Parcel Identification No.(PIN) PAW a /I /Oh?.g3 , - ,3 y?7. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I. ��" s'" r• �� g 1 (if well field,one lat/long is sufficient) 22.Certification: D FT 1 5 202 3 N 3ai /' , 6.Is(are)the well(s) Permanent or Temporary Signs o Cert ed Weil Contract 4° >lf2ate By si ing this form,I hereby cc•fy that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: °Yes or IDNo with 15A NCAC 02C.0100 or 15,4 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: You may use the back of this page fo provide additional well site details or well 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary. construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells drilled: Ot SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 da s of completion of well For multiple wells list all depths ifd Brent(example-3@200'and 2@l00') construction to the following: Y p 10.Static water level below top of casing: 04 ft. If water level is above casing,use'•+ ) Division of Water Resource,( es,Information Processing Unit, 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: In addition'ro sending the form to the address in 24a 12.Well construction method: Rotary above, also submit one copy of this form within 30 days of completion of well g rotary,cable,direct push,etc.) construction to the following:(i.e.auger, Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 l 13a.Yield(gpm)_ 20�/7/ Method of test: Air lift 24c.For Water Supply&Injection 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.Disinfectiontype: 1 1/o Tabs Y 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 Water Resources I, Revised 2-22-2016