GW1--00456_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey t4. haei zt lv czd V-, M. : M I '4
Well Contractor Name FROM TO DESCRIPTION
o 2°ft.
a.Na-rt SioW frckfor,geic
NC Well Contractor Certification Number 1 .`lC)A"S 1SZO.t 7 INti"(f6r 3utiRRase 1t4 cF�`RA ,',_ ) isg
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL -
Company Name 0 ft 55'
ft' 6.25 rn• SDR 21 PVC
`/� ? `��,./y c.1'6 P3i�Ff it alaitit011 0ker' ek�ma lusetl dp}t}°M-�4 y._.` '- :
2.Well Construction Permit#: ackA 42103— �J,116 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: '.t SC tEM' :` rx='''w.., W �r Iu ,S.� 4T d:rZ
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural OMunicipal/Public ft. ft, in.
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single) ft ft. in.
DIndustriallCommercial E3 Residential Water Supply(shared) o cs ^ x ,:_„r61m „„ , � me
E3Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft Bariod Hope plug Pour /1//�til s#A
Monitoring Recovery ft. ft. i ✓✓ JJ
Injection Well:
ft ft.
Aquifer Recharge E3Groundwater Remediationz
9r A /allAYEIr"`r.g,Q£.(a£app$t b7 ,k.ati;:' 4' .,,. 4
Aquifer Storage and Recovery 01Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test OStormwater Drainage ft fL
Experimental Technology E3Subsidence Control ft ft.
Geothermal(Closed Loop) DTracer 'a tixt 'C,. i€ r(a°ieac)x-a itivaa" sheefs aeeecsa"),,i a k .
.:.. Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM T,, D CR�rt tory lolor,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed: l�/37 3 Well ID#1QTJ g /5 ft. 3(f' ,pG_up( v 5ef J J
5a.Well Location:/ /�/; /` (' 3s ft- !r ftFri4/.t ' $c `O�/
C .e _1 1'.,a S G1!'irr/S s/Giv�inJ Lei! cft IIf ft t rzha.)�, SJ�.
Facility/Owner Natrle * Facility ID#(if applicable) (ft �O ft /Wi $ri �?oc`j
10 .: krifrr4gDr, Saftlidei Ire• 04 J0 ft. (D '" ft 6tttt3��� C oCk '\
Physical Address City,and Zip
«Old/ Gass v?')p3— s9—vyg 11. . _ M_ M
County Parcel Identification No.(PIN) '.k t ‘�c 'i (
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 6
(if well field,one latllong is sufficient) 22.Certification: I JN N .1 2024 J^
N W i4i1 M.s%r3.`
6.Is(are)the well(s)§3Permanent or Temporary
Si of Ce fled el ntractor I-, v�.0 � Date
By igning this form,I hereby certi t t,lhe well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or )No w h I5A NCAC 02C.0100 or 15A N C 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:
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 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: OI 1/5"I (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: I
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
Rotaryabove,also submit one copy of this form within 30 days of completion of well
12.Well construction method: i
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS/! ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 66AV Method of test: Air lift 24c.For Water Supply&Iniectio i Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: t 110 Tabs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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