GW1--08070_Well Construction - GW1_20231215

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
I
Joseph Bailey 4MWATERZONFAMITEZW4M4:1701EtS.41%,11K,MreglfrlaiM
Well Contractor Name FROM TO DESCRIPTION
3271-A d.JO ft. Pa ft. Si c/Ji?ce/'t ,z,/G
ft. ft. I
NC Well Contractor Certification Number
15 OUTERCASING(for lef s)caret[well ORIIINER(ifap Hcable}�;r: �� Mffa
B&K Well Drilling Inc FROM riTO DIAMETER i THICKNESS MATERIAL
h ft. /� ft. 6.25 m SDR21 PVC
Company Name ///Vy��� /ef� v 7
V��'arP ad u oV V!3 _. at*.INER CASINOOR':TIIBIlNG.(geatll althitiSO lki .z.„�,s,;: ,.6 <;
2.Well Construction Permit#: d 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.
Water Supply Well. ;17 SCREEN.3l. :,x,..)a 1:lel u,.",_.Vv iiiii 3,M, ._.n..n a, t,*._s,,l r .e= i.e,
FROM TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) BlResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) ,,;1&'GROUT :. s_",,M.;, z 'r azez a k ,,, ; ` "t"
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft Bariod Hope plug Pour a ® #A,
Monitoring Recovery ft. ft. �J✓
Injection Well: ,
ft. ft.
Aquifer Recharge DGroundwater Remediation
419.SANID/GRAVELPACK(tapplatli), -MX a _ l ,i
Aquifer Storage and Recovery SalinitY Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer `20.Dh1I LINGLOG,(attichad"dlbiunatsheefs:i[aecessacyj :AWE '? ,£:t •
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRI ION(color.hardness,soillrock type,grain size,etc.)
0 ft. id ft. L Sol
4.Date Well(s)Completed: l�a/a3 Well ID# i(/Liiid / 'b ft (S ft. of 7
5a.Well Location: � fr. d ft. f/c/low /yJ/ say i. •
/coo rq i Oett7e5, �-a,S )0 it y rt. Src �/sit vio.,-j
Facility/Owner Name �j� Facility ID#(if applicable) O,rS fit. I / )ft. CQ 'f'' / �k
t7/`!, CAOrIalf /�tf6011 nit RIP /((JJ/0 ft. 3GV fit. J�,,,rasra1 AC?C i
Physical Address,City,and Zip„rt 4 ry��/ 9 fit. 7 fit. f/
Cl e11 Co- /(5 ^1 '—44 x,21.-I SN'1•AR1cs...,tiJaTz.£E.,.fi s. am.x;rH a�.:,M, s r.,wvs ki .Kfisa iii §n:;:_:wt-M`:>>ai l
County Parcel Identification No.(PIN) "-" -- --•.-
a.‘ E,4.e g..m ii, A0/r '3
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ___,
(if well field,one lat/long is sufficient) 22.Certification:
DEC 152023
6.Is(are)the well(s) iPermanent or Tem ora tore Certified We-ell C tractor C,,,. iJa0.03 t 6`
y signing this form,1 here y cenTtb,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or MNo 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#2i 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,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: •
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3%✓ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) 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"+" 1617 Mail Service Center,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
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I•Se(7/'r'/ Method of test: Air lift 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 11/OTabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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