GW1--08120_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only: '
1.
1.Well Contractor Information:
Joseph Bailey
1ioN.A-TER-l- m ak „F. zi _- .._. f x Kv. ,wi`
Well Contractor Name FROM TO DESCRIPTION
3271-A kat /43 ft. 44-4e! frrf 1 204e-
ft. ft.
NC Well Contractor Certification Number
B&K Well Drilling Inc FRMI3TERILx O G,(for",fmultl-METERe1IST ICI (s MATERIAL` 1{iiitlY
Company Name /�/�/J 0
ft �� ft 6.25 I' 1O• SDR 21 PVC
/ j 1, `t� 16.:1 NER.GAMO,FOff`IET)BING fnco he hill!rated l6oi 3 ` ':aS, i4F`°. vl;
W
MI
2.Well Construction Permit#: �jj((�J. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) D ft. G ft f i Q V
in. se E 0 itr
3.Well Use(check well use): ft. 1 ft. Y i in. •
Water Supply Well: .t17 SCREEN :. M- k..I ', Y
,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) Et Residential Water Supply(single) - ft ft in.
LJIndustrial/Commercial Residential Water Supply(shared)
1..&GROTTINUNOi s gilt ...Ks ::a i 1'Iw4r .i5'-,.` °t414: . a, , W-44: xq e,`,..°
Qhrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft Bariod Hope plug Pour ft1 0Monitoring Recove
Injection Well: ry D ft. /Q "-•/''
fit. 7___I Am. Ayr �j f
ft fz ^�'/l �jklbf �--
Aquifer Recharge Groundwater Remediation
A;SAND/GRiL' L CCIC'(ifapj leahTe}..'..,.';;;' Z. _
Aquifer Storage and Recovery oSalini Barrier LA MET -�
6�d' ry FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test °Stormwater Drainage ft ft
°Experimental Technology °Subsidence Control / ft. ft.
Qi Geothermal.(Closed Loop) °Tracer . .20^Mull`3,11+IG>11 'azttac#iaddltioa'sfs7teets°3faecessar;px,l E-*, R a,q„,;:�:�
QGeothermal satin Coolin Return) FROM TO DESCRI Ion(celoq hardness,soll/rock type,grain size,etc.)
g/ g) Other(explain/under#21 Remarks) Oft �ft RC to f�
•
4.Date Well(s)Completed: �/ .i) Well ID#l or5, j`ft. 3�ft. 4J Q/
5a.Well Location: 7J�ft. �O ft. fin44 4et; 4,„71 W G/4
�r11 ugtf Horle51 La, Pne,# m2id so ft. ysn -y//ei# iQ c/4f Qt /
Facility/Owner Nai a Facility ID#(if applicable) Vrft- , I v ft- ni_+ 'L__ Q n_cfc
5S0I c)er,o i Ri at elar',A geol4F 11 o '-fgq t. G � /�Ck
Physical Address;;City,and Zip / ft. fit �(� •
irledfieitbrig ea , 64.,.. Q3ss a t1:tEMA wsvi lm, `"" �^mtl `1 ¢- - =_ ,- �,r,�s� l�zs�. a t _ell
County Parcel Identification No.(PIN). 1�t✓ef( a/'1r�1e(Jl µ loht,3a� - •�y, F^ �!iY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certific lion: BE C 1 5 LU/I p3
'X d36.Is(are)the well(s)0Permanent or °Temporary Si of C rtified a Contra or li:v�� '�''�Dat
signing this form,1 hereby cert:that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or EjNo th 15A 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-I 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: 0 �L+s (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00) 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 1/8 (in.) 24b.For Infection Wells: In addition;to 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
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
y� t
13a.Yield(gpm)�1r/G/'d Air lift in Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
Chlor Tabs t 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016