GW1--08130_Well Construction - GW1_20231215

•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information: f
Joseph Bailey 14 WATERZ41ES ,. RW x', .' ,a a`ra€ramIWXW
Well Contractor Name FROM TO DESCRIPTION
3271-A IS ft. Y ft. L4 ie!1-+rurornc 9
NC Well Contractor Certification Number elfiZOIITEg,CASINO{foi tutMgcBse .Wells):OrtnMe(fra 'tica`"b"liff,f 4,77 F-zf
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
® ft. ..50, ft. 6 25 , in SDR 21 PVC
' fia / �i �YNFV 6: I<;1t��ASIN�OR�'1T)BIND.{geotherwat_clPse��o�P3`-�� x: t& �e' ..:'��;IA
2.Well Construction Permit#: cur - 3 4 I) 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.
d7
Water Supply Well: SGREEN; Zw -x .w _ws 's �., :
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
°Industrial/Commercial °Residential Water Supply(shared) A8GOUS` 4 t7,u y lx � IM.F §
fi
T _ c N°Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. Bariod Hope plug Pour /9/.1.1s//,
Monitoring Recovery ft. ft. I
Injection Well:
A uiferRechar e ° ft. fr k a s r )1 &7 j ,
4 g Groundwater Remediation
Aquifer Storage and Recovery �J Salini Barrier 19.S` �7D/G1tAYEI AtLfifappReabte}, ., �, , „ ,w 4,,
ESP ty FROM TO MATERIAL (EMPLACE L `METHOD
Aquifer Test °Stormwater Drainage ft. ft. r l+
°ExperimentalTechnology °Subsidence Control ft. ft. In r-r.5 r r;.!.y. ,j-; CO
°Geothermal(Closed Loop) °Tracer 201 DItILIiIND:E G((z[tacfisrldittat a he Slf eceisr ,: } ,, ° QN
Geothermal eatin Coolin Return FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
gl g ) °Other(explain under#21 Remarks) ft
4.Date Well(s)Completed: fQ/iq1 3 Well ID# i0rf' f ft• a ft, /?rdid4 5.0
r'1
5a.Well Location: a(ft. it ' ft. pifoG.a ,,n 5 v4rqe/
-, /
El ire t✓4lis [-Lc �OtI1Stieh.f •itlYlf g7 f`' 5 ft. /ri � Sc,
/
Facility/Owner Name Facility ID#(if applicable) [�� ft. / .ft. 47 / !?oc/C
/a'oc( o Or_ _54/' 7HC? /yam &(-ft. a(�o ft. if�,l Rd etc
Physical Address,Ci y,and / ft. ft.
jt�o Wl 60.. a6/ A U a1sRETvfARIC9;r.; z .. _.: h $ {
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific on:
N W / /0
.
6.Is(are)the well(s)OPermanent or °Temporary o c ' ed ell ctor Date
y signing this form,I hereby certify t i.'I the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or ONo with 15A NCAC 02C.0100 or I5A 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 t the well owner.
repair under#21 remarks section or on the back of this form. i
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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
a
9.Total well depth below land surface: (ft) 24a. For Ali Wells. Submit this form within 30 days of completion of well For multiple wells list all depths if different(example-3@200'and 2@/00') construction to the following:
10.Static water level below topof casing:40
(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Cetiter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Rotary above,also submit one copy of tliis!form within 30 days of completion of well •
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
I
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�}
cA I
13a.Yield(gpm) 30�/' 1 Method of test: Air lift 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1/0 Tabs the address(es) above, also submit i one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction o 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