GW1--08121_Well Construction - GW1_20231215

i I
WELL CONSTRUCTION RECORD(GW-1) 1
For Internal Use Only: ,
1.Well Contractor Information:
Joseph Baileyiii
1loo ATER ZONES..,.: E .,.s.:.mia,kir4 ;?4.h j ,
Well Contractor Name FROM TO DESCRIPTION
i�..• - 7..<J..:
3271-A 260ft. '/„ et. / /C fmaii e Are—
NC Well Contractor Certification Number ft. �'�7 ft. d
B&K Well Drilling Inc 'FROM
FER.CASING;{fdfmulttcasert.wellsjO HIIKNESifcaji"liMATERI
TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. i
/{O ft. 6.25 I ! 1n' I SDR 21 PVC
; ��o�3 516 NNER-CASIING OR TU�BING'(geothermal ciaseiiftieji) ,,,..1"—°�a r:
2.Well Construction Permit#: FROM TO/ DIAMETER THICKNESS MA ERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) O ft. /S3ft. pi, in,
3.Well Use(check well use): So!�� �•/
ft. ft. i, in.
Water Supply Well: .
l SGREENOVI <. .,tg.„I" ai4 H 4I V_...,t=. giVe, c_t ;ra I: N` its.'
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply 1 (single) i
•
ft ft. '°
Industrial/Commercial
Residential Water Supply(shared)
• IIB.`GROUu :kr -3xsz 'F. .+ s fi k-. ne q
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT/
Non-Water Supply Well: 0 ft 20 ft s�//'
Monitoring Bariod Hope lug Pour
Recovery 0 ft.
Injection Well: A ft. /idyl J1 "�Y i- our 4,j Aquifer Recharge DGroundwater Remediation ft. �+ ft. !— ! 71 t U� e�D� /�V'
Aquifer Storage and Recovery Salinity Barrier °19` D/GRAVEL PACK(tfapptic ble) , 7 .,'.
FROM TO O :..A'^`�*rrx:'
Aquifer Test MATERIAL EMPLACEMENT METHOD
�StormwaterDrainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20DRILL1NGal '
AF(atfachaddltfeaalsheeta'iinecessary) -': ky2 .„ O
Other(explain under#2I Remarks) FROM ToS sC� DESCRI 'ION(colof,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return)
O ft, l�r---ft. jleso,�/
4.Date Well(s)Completed:04 o3 Well ID# AO/ 2S...
'pt. /D ft. /3ri :?J f'//
5a.Well Location: I 40 ft. l(ft. R_1��1i Js v 7 e i-c/
jm'f1 I% d fi'Ily
a-C. -//Ia9.e *5 ft / ft. y6(!I/.d✓, ry .i.5" /l,
Facility/Owner Na a Facility ID#(if applicable) ft Oft ro C
l J3 � �� c �#'G//
3.S q Adgf a1 Rd., C,4grloffi Ale_ a8" , 13v ft- 114 ft. ,Efn,3 er key
Physical Address,City,and Zip � g) ft. �j4$ft. fir,,,,,
Inee<le f Co �y -oil-a 1 �W cJW a ;.i a,.�r.,..iia'�� n'(Q
County Parcel I entificationNo.(PIN) fJw�f/rt � � �/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' y d^d1
t.c_._'.tk:'a.__is b ..-,?_.=.4(if well field,one lat/long is sufficient) 22.Certif ation: DEC
N W i / i
1, 1 ,; z�21
6.Is(are)the wells Permanent or Temporary r ture of rtified Well Con :cr$r Il;»; =v ::$i 2'=,,,3tD,a
•signing this fam,1 hereby certify that the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or EliNo . ith 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 thewell 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 details. You may also attach additional pages ifnecessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
70� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths iifdii erent(example-3@200'and 2@100')
2
(ft) For All Wells: Submit this form within 30 days of completion of well
construction to the following: i
10.Static water level below top of casing:40 (ft.
limiter level is above casing,use"+ ) Division of Water Resources,Information Processing Unit,
61/81617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield �LL Air lift 1
(gpm) 6 04 Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabsthe address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/0 Tabs completion of well construction to the county health department of the county
where constructed. !
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016