GW1--00477_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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1
Joseph Bailey 4MAuq zc Ngsi --- . .:U ,_ --x is x_a m _
Well Contractor Name FROM TO DESCRIPTION T�'
3271-A ate t'Jt•ft a•ft, /'Y4041 'r,6/Urc 2,0fJ-e
NC Well Contractor Certification Number V IO"' ?17X fL e rqb
5tVMITEREGASIII(sfftir`inuGtE--assert vE =filCl k{SF` <"to ,-'w `
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
ft.
ivyft. 6 25 ' m• SDR 21 PVC
Company Name l 0 ,
A•7 U ��� ,_ ;. " iG� INOxCIJ}e�n ;cTosfd „�.�.<,?.x;, ��,oM�.:`;
2.Well Construction Permit#: CO— (//9 a / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permi UIC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): ft. ft. in.
Water Supply Well: —..ii .� `..a ; A -�" , 5
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) raResidential Water Supply(single) ft, ft in.
0Industrial/Commercial Residential Water Supply(shared) 8' R©'(3T w ,x, qr. -
i T Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT v
Non-Water Supply Well: I ft. 20 ft. Bariod Hope plug Pour c_".,:" ;{'^try S1 �� 747
Monitoring Recovery ft. ft. + - ter' ti V I--,Li
Injection Well: _
ft. ft. JAN 1 G 2024
®Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMpII j1IE1i'I,METHOD.r,.u Y5i
Aquifer Test 0Stormwater Drainage ft. ft. ! W •B,
G
®Experimental Technology 0 Subsidence Control ft. ft.
OGeothermal(Closed Loop) °Tracer .2'11:11R11 Zs1110,^CNC(i tlacas+i'dittiiroa'lsWe
Geothermal Heatin Coolin Return) FROM TO DESCRIPTION(color, artiness,soiVrock type,grain size,etc.)
( g/ g Other(explain under#21 Remarks) Q ft.
t ft. F�/t 1
4.Date Well(s)Completed: la/b,/a3 Well ID# 0 ft / / J�390 a
7J r/
5a.,We�e Location: /,cft. J,f. t O v'4 ,Sal !
34 frlinit,ier 3� 6S'ft yekid Yrow B c i$1�l
Facility/Owner Name Facility ID#(if applicable) /$✓ft 15-ft /y ,Qi`�� CIF sei/
V it 11 A/c Kj1M / fticoresr.;/I Nc4 114‹ (y�s'ft- w ft- tq�9srifi Physical Address,City,and Zip 0 ft ft. i ire..Ra c/
Reswal
.730-0q
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.Certifi lion:
(2441
N W 1
6.Is(are)the well(s)JPermanent or Temporary Si of ifie Well Con ctor ;" Date
By zgning this form,I her certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or EgNo with 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pageto 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
01
9.Total well depth below land surface: 11 ) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdtfferent(example-3@200'an 2@I00') construction to the following: 1.
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 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
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6/3 7 Method of test: Air lift 24c.For Water Supply&Iniecti!
/ n 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: 1 1/0 Tabs completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016