GW1--00450_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD (GW-1) calUly / '
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1.Well Contractor Information: IL .
Joseph Bailey 14.WATERZONES :.1;` .;.:r '..
FROM TO DESCRIPTION Well Contractor Name
3271-A X.lift. O 91 fi-eIrj-4,67- i
764'
ft. ft. I ,
NC Well Contractor Certification Number t,
1S.OITTER:CASING:(formulti-cased:wells)',ORLINER;(ifa liable) ',<i
B &K Well Drilling Inc FROM TO DIAMETER; t THICKNESS MATERIAL
�c 0 ft. /-f ft. 51/2 in' SDR-21 PVC
Company Name 3/kg/6.S w',r /Zd ''11663NNER'CASINGG OR TUBING(t eotliermal�closed loopy ":/ •
^6Q A FROM TO DIAMETER] _THICKNESS MATERIAL
2.Well Construction Permit#: o�• I ft. ft. �i"• (( ,`J� �i
List all applicable well construction permits(i.e.WC, ate.Variance,etc.) Q 6 o S4.._4#
ft. ft. 'in.
3.Well Use(check well use):
11'SCREEA :
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ElAgricultural °Municr al/Public • ft. ft. in. .
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
°Industrial/Commercial °Residential Water Supply(shared) .:.18:GROUT '. t •.. ',,..
FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Irrigation it. r�0 ft � o o r/ 4a 13e#0
Non-Water Supply Well: Ot �� /
Monitoring °Recovery ft. ft.
Injection Well: ft. ft.
°Aquifer Recharge °Groundwater Rcmcdiation 19:•SANDiGRAVELPACK(if applicable) '
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
OIStormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tmcer
20.DRlLLINGLOG(auachaddtttooalsheetsdnecessary) •'.::..
FROM TO DESCRIPTION(color bardnesx soiUrock type,grain size.etc.)
°Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft. 7Ci Sd /)
it/ �J' �/ ft. ?19 ft. dirk/s7 s'aI I
4.Date Well(s)Completed: /�/23 Well ID# /�(// r.� 'zJ L,('� ,
RO ft. 3Sft. ye`>/d Al/31��1 Sa ,l
5a.Well Location: / �� Pn ft ft ���/// �f
t Il0 of ac p0tAe , n ftc J�ft qr ft 6 //1r_G_,i/// s44y r /
Facility ID#(if applicable 40 t,•� ,� 1t/ 5.y�J j' '
Facility/Owner Name J � / �.� ems/
/03 S ) V I r-JL///c/ Sr7j riiJ k 0�25G)5 � ft. ft
3d� (-(4. e/10 c4
fr
Physical Address,Cil and Zip ��//II�� •� l � •. •.: .• ,,... _
22/1 RE14LAtRICS
1t"eJR.II �- l fit/ +� ( Von-self . ,,r./ /lYqj3 ::
County Parcel Identification No.(PIN) t
�l�.w( A a i G.� .�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Ce ;nation:
(if well field,one lat/long is sufficient) / T J A N 1 G 2024
N • W / 72*/,_1.
1/ ;;rirr tan rIT:-..4r.-3 lfl�
urc Certified Well C
6.Is(are)the well(s)0Permanent or °Temporary • J G}'vy€;/was(k
v signing this form•I hereby c•ertiji•Eh!at the we 1 s 1 (were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or Iv
15A NCAC 02C.0100 or 15A 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 alsoattach additional pages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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' nd 22 100') construction to the following:
40 (ft.) Division of Water Resources,information Processing Unit,
10.Static waterlevel below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: j
(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
(SP do lP/17 Method of test: , /s �� 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield m) the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs Amount: 11/2Lbs completion of well construction to,the county health department of the county
13b.Disinfection type: where constructed.
fir:
Form GW-i North Carolina Department of Environmental Quality-Die Sion of Water Resources
Revised 2-22-20 t 6