GW1--08064_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: � l' .
1.Well Contractor Information: j
Joseph Bailey
iiii4 f ATEIC ONES s; .7 , ,s,. s ( T
Well Contractor Name FROM TO DESCRIPTION
3271-A /#0 ft. /WA ft. $A2f/(�G7/rr.Z?,i
NC Well Contractor Certification Number $7,* G o.math wt + rlr`Get°
B&K Well Drilling Inc TO (fi R )atCKNESS MtileTERI _ � ;
DIAMETER THICKNESS MATERIAL
Company Name /� a ft. y�t• 6.25 , 1°• SDR 21 PVC
/c►(t ,cal�0��' ���B� xi&fNNER,CAS NaGRAtitllNG iiithetnitirelosed4614}� k Tn
2.Well Construction Permit#: fJUff//- / FROM TO DIAMETER THICKNESS MATE L
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) D ft. /o n C�—ft. L/ in. tt"
3.Well Use(check well use): ft , /�
I, � "_
ft. in.
Water Supply Well: t ;I2 SCREi,'N..:a_a Ei=. , , ,; ,..s a :_.A:£.,. ei;. ., a:> r irl
DAgrlCllltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
FROM
ft ft. in.
DGeothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
llCommercial ft ft in.
DIndustria
Residential Water Supply(shared) 'Itomor y^Y ,
Irrigation .-.g...,r: w
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft.
Barlod Hope plug Pour / �tV4_l
__ i
Monitoring Recovery /
ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation ft ft
Aquifer Storage and Recovery Salinity Barrier 191'SANDI,GRAVEI PACI[(r€,ipplieabfe} ' _ x 4-s ;f r
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
®Experimental Technology 0Subsidence Control ft ft.
DGeothermal(Closed Loop) OTracer ZOFDItIT.LING;}t?G{(at chariditianitlsheetiifn'eees
DGeothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness soil/rock
( P,/ g Other(explain under#21 Remarks) �j /� type,grain size,etc.)
4.Date Well(s)Completed: ��OZ�f/"�3 Well ID# p2�'T9 0 f t. /+ `�e4 5on
1 5.-It.
ft. 3S it. d1v j e, f
Sa.Well Location: eft ��ft. .r� �0�7 $44 J
I 37Bg /
P4!/l r'e/S,Ct Serene L.4kk J U ft. ,eft �etid •!Yr/�w S' 5'0,7 l
Facility/Owner Name `J /!/ mFacilityID#(ifapplicable) ?�ft 1,�,t) ft R k ` ftw
i/,26f� 1/ore wI N<D`t. /'/ q I is g/)ft. ( r/ft. v r f 4etas dI��6� /' /j'I � ;df7lloe%
Physical A ess,City,and Zip ft O t
� c 11 Co- 4�,S,S�!G-�qys .s° `?� . '` Axa f
//�� � _ .v , ..
County Parcel Identification No.(PIN) IDYa4,..oil / I -cif !7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) y
22.Certification: OF:(: 1 5 2023
N W
6.Is(are)the well(s)0Permanent or.Temporary �*V �!' /
Si a of ertified Well Contrac Div b-..;'3.,}G Date
signing this form,1 hereby 6 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EgNo with 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#2!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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
l,��� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (� (ft-)
For multiple wells list all depths ifdli ferent(example-3@200'and 2@l00� 24a. 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
If water level is above casing,use"+" ( ) Division of Water Resources,Information Processing Unit,
1/86 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: I'
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3/m Air lift I
J Method of test: 24c.For Water Supply&Infection;Wells: In addition to sending the form to
13b.Disinfection e: Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
1 1/0 Tabs
tyP 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
1