GW1--01832_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
Joseph Bailey ;Ia:WATERZQNES ., , .' ,,,.
Well Contractor Name FROM TO DESCRIPTION
3271-A . 9 ft.95 ft ?edit ' f�le.7
NC Well Contractor Certification Number sir aOft. /Ata
it. "G9 X„v 6-7o/_( (t
S:!:7#UTER:CASING:(for.in ;casedw/ellss);OR3:INER(if •licable) .:'.., ,t.
B&K Well Drilling Inc FROM TO DIAMETER' THICKNESS 1 MATERIAL
Company Name eb ft. 6/ / ft. 6.25 I I tn• SDR 21 PVC
(� ��,,//�/ '.-l6 NNER`CAS IINNG3oR,TUBING`(geothermairclosed;luoM .. :a-*
2.Well Construction Permit#:4®/" �(�� /9 FROM TO DtAMETER1 THICKNESS MATERIAL
List all applicable well construction permits(i.e.U!C,County,State.Variance,etc.) ft. ft. ! in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17S.SCREEN,<„ .W;: ; . . = . ,'.T,x _, > m't ,
FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
©Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) ft ft to
DIndustrial/Commercial OResidential Water Supply(shared)) ,. .
,18::GROUT, -4 a..,>.-,, , _..,a m.. 2z4`
0 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• Bariod Hope plug Pour //QAy�gip
Monitoring °Recovery ft. ft. Wa�U
Injection Well:
0Aquifer Recharge E3Groundwater Rcmediation ft. ft.
419.SANINGRAVELPACKfifippHcs6le)...
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (I Stormwater Drainage ft. ft.
0Experimental Technology ()Subsidence Control ft. ft.
()Geothermal(Closed Loop) °Tracer .,-20 DI2ILIANG!1OG(attachsiidititinalalieets33itiecessary)=do- r.::;,,:r >.
®Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
( g/ g EIOther(explain under#21 Remarks) A i
O ft- j v ft- "Zed di I .
4.Date Well(s)Completed: CVOV Well ID# L er69 i E�ft. 3 ft. er-d 0/,n S6)j
5a.Well Location: ft. ft. '/ fi y�I,J f Cal/�j
rI I ('e t4/Q II) t L fire ern.S aft. ft. iyie /41 l OJd\
Facility/Owner Name Facility ID#(if applicable) ('ft. 9®S t4 6 P /?d4C
I a S5 cop erATi 0 r',5q 1i3 N 3Ik1 ft. ft.
Physical Address,City, d Zip 1t?� , -Th
rO Li 4 4C0o c901,16(09 .5.2 t REMARx5 Ax ... ` .,.,.,. . ..,7 ;I�:'y': ., ,.., s;,«;,i ; .'; :c,,
County Parcel Identification No.(PIN) I, MAR 2 2 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IUt !
L iC%.t; r ^'� R J rt
(if well field,one lat/long is sufficient) 22.Certif,f on: ('ir.
�/ Ctttr 0;'3 JL?
N W / / ,,
field' /44.4./. './ ' 124Z/5/*
6.Is(are)the wells)JPermanent or fiTemporary Si 'of e'ni Fr. ell Con..Itor Da
By igning this form,I here:v.rtiAr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No w tli'7SA NCAC 02C.0100 a !SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction 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: t 65' (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: l'
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) iy Method of test: Air lift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs 1 1/0 Tabs 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016