GW1--00428_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Joseph Bailey _1a Atrsg N ig - ,4
Well Contractor Name ` FROM TO DESCRIPTION
3271-A /Go ft. /4.2-ft. . ..114 jene
19$ft. a, ft. sue,/(Pg4fere Zox
NC Well Contractor Certification Number
5TOITI EIt GAS11!TG'(foimnitl ¢tid .It itifi p "' enVairA#. a
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. /1(y I ft 6.25 1O' SDR 21 PVC
�" / i?rt-. A1ERG'ii$MG1OR: —G`tfieotlteciga4ctuseY Yvbli, n_ ` iRn
2.Well Construction Permit#: W€/!—O 3 aoa3- 17C �y i/G 4 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 fr. in.
��.
Water Supply Well: 37:SCREIw= r ri .r . . .4 k .x._ xa 3 n.FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•Agricultural 0Municipal/Public ft. ft. in.
X Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in
X Industrial/Commercial °Residential Water Supply(shared) y.,,yig
:18:�G$Omiti"t.. Wm �.?�skr xXmiN }"'s�a�s�t �vM _,41X0e-�s'',�'
Irrigation ('^g r"l 7,7,7'p f r"r") FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R L.LP L.i V lt_.„,l../ o t 20 ft Bariod Hope plug Pour /t it's.X Monitoring Recovery
Injection Well: �. /; .N G 2024 ft. ft
ft, ft
illt Aquifer Recharge °Groundwater Remediation .
1 i^,� :4,it f r'C'^v.f.ore.43 I.iPr ,,,19._& !1D/GR 1tL:P 10( IiT stable ' .Al wt;-..dh'.c ',.,.1 ,
RIAquiferStorageandRecovery LjSaIinityHa7�T�, �-�,_ EM �E 'Hg
t IJ'V'8�','�iVL.ro FROM TO MATERIAL EMPLACEMENT METHOD
X Aquifer Test 0Stormwater Drainage ft ft
5 Experimental Technology 0 Subsidence Control , ft. ft.
S Geothermal(Closed Loop) °Tracer 41.0 D EL11\"G`LOG itacl idil rariKe"sSif aecessncy W ;„,�,,��- SAit;
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
X Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)1 J ft. /b f. Ric"' go:7
/y
4.Date Well(s)Completed: / -pii' `
,P3 Well ID# eTh( /0 ft u6 ft- Entire, co A
5a.Well Location: 04' ya ft. /(ft tI.4 fartiVe (,�►G/
OiIr taint aV 'i 4/ynS PhA '},S'ft lbY,3 ft "�L ;5.y �'r-Wrj! f 52y/
Facility/Owner Name Facility ID#(if applicable) / eft` / 6 ft. /`-`! v $ //
y 3 N LinmSwei r©c, /7Jer4e�n a8O >30 ft I So ft. S ifflrGrey o0 i�+
Physical Address,City,an Zip / / � ft. (kr% i. ,,..' / r
C4?4l✓6q Go 34 ) O�b21325' l,�ImEvok S �..�' -v ._ `u ' r rz o.rj,:, )
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.Certification:
i
N W /
6.Is(are)the well(s)JPermanent or 0Temporary Si rti d Il ntractor Dat
By gning this form,I hereby certify I the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or jNo wi 115A NCAC 02C.0100 or 15,4 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.
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-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: 0,5
(ft-) 24a. For All Wells. Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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 /$ (in.) 24b.For Infection 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) Method of test: Air lift 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs 1 1/0 Tabs l "
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