GW1--08123_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD(GW-1) ��tbF
For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey
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Contractor Name DESCRIPTION
Well Con
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3271-A /,r�4" /fa ft. �, rly Zc e
•NC Well Contractor Certification Number ft.
I'I,
B & K Well Drilling Inc FRa5ZOM rEg?cTO lriir ,DIAM eaiiialS�.O HIC NRSft -ri 1T)MATERIAL
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FROM TO' DIAMETER THICKNESS MATERLIL
Company Name 0 ft I /,Id.ft I 6.25 ! rn• SDR 21 PVC
D f MINER CASING UB?£�liBlNC4geothee5a.Wailed ioujxj tirk
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permit (i.e.U!C County,State,Variance,etc.) 0 ft. /3 7 ft. rt m. /�j
3.Well Use(check well use): ft y I soil(jQ /'YG
ft. in.
Water Supply Well: 17uSCREEN:, .>. ;,-_s 4-a . h sr s }.. , F M i ...�.>.
AgriCLLltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) r@Residential Water Supply(single)
Industrial/Commercialft. ft. in
[Residential Water Supply(shared)
Irrigation
1&GROl]TEA+.t a et k
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft
Monitoring Bated Hope plug Pour /
Recovery b ft. / ? ft. 'Q� M ,t1 e/t�
Injection Well: J [n" /'•f p�/�� 1
Aquifer Recharge °Groundwater Remediation ft fit g4 L�f /'81'�HG
Aquifer Storage and Recovery Salini Barrier µ `l 'D1 � LPACIC IFithie) ;_ �;E�,OZOMAS,
ty FROM TO MATERIAL EMPLACEMENT METHOD
r
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer
20AI ILLIN�L00-�aitach iddTHiffidiffelis;7faeeessrifb3= a:, 7:W ,.g;
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRI toN(rnioq hardness soi/rock type,grain size,ere.)
Ø4/'25
/
4.Date Well(s)Completed: Well ID# L0T 5tp �v ft. y�ft /Q�um cQ j�l
5a.Well Location: /r/ft 9c) ft ekii , Will -i , s64
flr7iay/% i&e5 file. F p ft //a—t't1 ty/OwnerNafie Facility ID#(if applicable) // ft• /as-eft
�we�f II, �_,prrA�,k
slat fogs Rd..;C�v% ,,�G a(a4q /25ft. !,ya,ftft. 3O .,ere, &e
Physical Address,City,and Zip Ca /90 ft. 0742 t � ei /Z0`��
,t/feck!mar D y3 03�- JV 21fI2E1F1'' ' n -1,1,1 ,71ffl z .,�r s qk ili
County Parcel Identification No.(PIN) UM QV 1 I e / - /r s P, r .
� s �3.z,• , ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one Iat,long is sufficient) a / D F C 1 1U f!J
22.Certification:.
N W �, int, Cil „..•
6.Is(are)the well(s) Permanent or Temporary ,v,...../
Signs . ofCe, fled e 1 Contrac r iJ r:'a is 1�ba f
By,'ping this form,I hereby ce fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EjNo with 114 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:
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 if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
t SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: d (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"+"
6 1/8 1617 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:
l
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Owi 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.Disinfection type: Amount 1 110 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