GW1--08132_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD(GW-1) . oiff, un
For Internal Use Only:
1.Well Contractor Information:
I
Joseph Bailey
Well Contractor Name 14:wATERzon :�,'4x�, C ,��x 1,7;e1M �, x,,
FROM TO DESCRIPTION "- '""' "`
3271-A Q it fr. I
Wit. 1,3,. , �t t T z.
NC Well Contractor Certification Number "-
B&K Well Drilling Inc is"° R wo'(r" mDIME �e�-oT lot m
FROM TO DIAMETER THICKNESS MATERIAL
Company Name • 0 fa 1 9v ft. 6.25 m SDR21 PVC
2.Well Construction Permit#: COP �95� is NEW C` GAIg= M{ge"othermad HICK oopZ MATERIAL
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UK',County,State,Variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: :I7gSGREEN, ,_; t ..�z.. . - ..,:N" if <: E g4 r i'f
°Agricnitural FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
DMunicipal/Public
Geothermal ft• ft. in.
® (Heating/Cooling Supply) Residential Water Supply(single)
DlndustriaYCommercial ft ft m '
Residential Water Supply(shared)
Irrigation iR`. 1F<iU7 ,,: '. n .: x" .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTS
Non-Water Supply Well: 0 (t 20 it
/c ��//11 Monitoring Recovery Bariod Hope plug Pour 2q ft. ft. !7f
Injection Well:
Aquifer Recharge Groundwater Remediation ft. fa '' .,.'it,: '°t j ;
Aquifer Storage and Recovery Salinity Barrier 9' D/D 'PA Tea pE�41e) r
FROM TO .ax.,E.e,,1 ......::�i A-:s,°.
Aquifer Test M� R�AL V '` )/EMPLACEMENT METHOD
ft.
0StormwaterDrainage ft. ft. 11
Experimental Technology °Subsidence Control
fir 1vri r n .'• 3 L;n
Geothermal(Closed Loop) Tracer _
IWD.RIMBIC. G�(att tirsil ditronat�s �£ue
Geothermal(Heating/CoolingReturn) FROM TO DESCRIPTION c aFys. f �,`'grai`size, F)° "
Other(explain under#21 Remarks) ft. r � (color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed://3/a3 Well ID# 5- ft J Red p, Qi
5a.Well Location: N ft. 4,( ft. Z.7,34 grew,sem ' ,7' /
/ -irtk A(Tao /keep ifs ft- Is- ft- )//%4✓13r.,..//e/4/d�564r///!
Facility/Owner Name Facility ID#(if applicable) ft fr ft. /
#cvf< ^ $ :up,,//' a fd/9f (/5 ft- 9:4;f . r .7/ f iQac%
Physical Address,City,and Zip ft ft.
•
Re) Co. 32/ 1Zl
.12E1N:4ItTcs°Z ., F4;::gA`rr'�'-,ZWW .- �-
ft- yr,
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.Certifica r r n:
N W
6.Is(are)the well(s)0Permanent or Temporary Six .tore of c�nifi ell Contra or
4/01
7.Is this a repair to an existing well: NoBy signing this form,I hereby ert�that the well(s)was(were)constructed in accordance
Yes or
i� with ISA NCAC 02C.0I00 or 5A 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. I
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 pagesif necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9�I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths ijdifferent(example-3@200'and 2@I00') ons c
VWFor All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resourlces,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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
/ ��� 1636 Mail Service Center,l
U Raleigh,NC 27699-1636
13a.Yield(gpm) 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!one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to th county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016