GW1--08068_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD(GW-1) ' `
For Internal Use Only: �•
1.Well Contractor Information:
Joseph Bailey i
Well Contractor Name
FROM TO ..:-, xr.__.saz3 * M %
DESCRIPTION
3271-A '
NC Well Contractor Certification Number
�'Z`A�
B&K Well Drilling In41.
ds 0: s'131;1IYtiormul
FROM TO t T ."1-C89et,1 i°O ':a'C y,• °i..a'1 MATERIAL
A a
DIAMETER THICKNESS MATERIAA L
Company Name Mill /0 ft 6.25 rn.
/ SDR 21 PVC
2.Well Construction Permit#: 6d 3 /(47�(� 6-'1M!iI=II. CIl�I #1t OAA E tb 2!ICKN i —. .ERIA YWCA_,;_
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) FROM ft. TO ft DIAMETER in.
THICKNESS
MATERIAL
3.Well Use(check well use):
ft ft. in.
_—
Water Supply Well: i SCRE ICATE -
*Agricultural FROM TO TER SLOT
F MATERIAL
c,
�Municipa]/Public DIAMETER SLOT SIZE Matiltd.tyy,� MA
* g Su Geothermal(Heating/Cooling 1 g�yResidentia ft' 8, 'in.
Supply) lCl Water Supply(single)
Industrial/Commercial Restdenhal Water Supply(shared) ft.
t ft.
t �n _--
ill Irri:ation
^, , 7,-.7) 'MATERIAL
.' RI "A z°a"'*- OD... 'AmN
Non-Water Supply Well: n' ' '� ' ' y'" FROM MATERIAI,
y �,'q,�+L..j, ,g ��„'_." EMPLACEMENT METHOD&AMOUNT
Monitoring 0 ft 20 ft Bariod Hope plug1221/11F /
Injection Well: �Recove t �, y
j L1 ft. ft
11.Aquifer Recharge Groundwater Remediatiop I i ft. ft.
iAquifer Storage and Recovery 0S�IiWcPB—a'ss I✓r R "� /G1t i � 41 Re y
ill Aquifer Test v cocua
pM
TO MATERIAL EMPLACEMENT
M* METHOD
.
Stormwater Drainage fL fL EMPLACEMENT METHOD
al Experimental Technology °Subsidence Control
Geothermal(Closed Loop) °Ttacer ft. fL
2
•Geothermal(Heatin_Coolin_Return) *Other(ex•lainunder#21Remarks) 11 attactt�ti oval irs
FROM TO DESCRIPTION(coloror,. �'
hardness,
soil/rock i.e,:rain size,eta))
4.Date Well(s)Completed: 9 T _Mil
/) t
WellID#_CLI / �. •'
Sa.'WellLocafion/+ ���� O)
?1^ �1ti1 /Bl)S/h�,ant•��! � t< O'C1'1/
Facillty�wner Name Facility ID#(i M —
applicable)
-3 I,
Nompjahn
Physical Address,City,and Zip I r
��/ C.G ft. ft.
County MARIC5 ". eel : .w
&dtthcauonNo.(PIN)� i�l 4.111rWallJr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: U�
(if well field,one lat/long is sufficient)
22.Certific 'on:
N W
6.Is(are)the well(s)S3pernlanent or Temporary t ure of ertifie el]Co tractor
Da
7.Is this a repair to an existing well: °YeS or E{No signing t is form,I he y certfbi that the well(s)was(were)constructed in accordance
with
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 thl�w well owner.ell Construction Standards and that a
repair under#21 remarks section or on the back of this form.
ite
am or additional
8.For Geo robe/DPT or Closed-LoopGeothermal Wells havingthe same 23 may luserthe back of this page lto provide additional well site details or well
P You may
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
/ os, SUBMITTAL INSTRUCTIONS I.
9.Total well depth below land surface: (4
For multiple wells list all depths ifdifferent(example-3@200 and z@look 014 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:4t) construction to theto following:
ft
I10. level is above casing,use ( ) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
Rota 24b.For Infection Wells: In addition to sending the form to the address in 24a
ry above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
(i.e,auger,rotary,cable,direct push etc.) construction to the following: If
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Q Method of test: Air lift 1
24c.For Water Supply&IniecHnn Wells:
Chlor Tabs the address(es) above, also submit one copy of this form dition to sending
30e days of
tab.Disinfection type: 1 1lo Tabs form to
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
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