GW1--01833_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: rjaFore
1.Well Contractor Information:
Joseph Bailey
aisminvzoNESin, : t t _ 'h 5 ,t o w n q r t t o¢�.,. �.�.a vita`.::,,-.Y. ,. i` .nth 8,; s�,4 •
Well Contractor Name FROM TO DESCRIPTION�
3271-A 3 Jft. 1 if ft 4iY- &T/e2,41
ft. ft
NC Well Contractor Certification Number
B&K Well Drilling Inc {FRO`M ,Orlic�(r°r taltr.METER Tl S Ttp TER ,?;,�e'
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft (� ft• I 6.25 I 1O• I SDR 21 PVC
C,dPjI ///7 u�16'`INAl SIAIGIOR TUBING;"g ttsed4aOA)'�,�"it i .2.Well Construction Permit#: ,p ( '�� cl � �� -'n `� ��} ��`
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 0.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. i°•
Water Supply Well: 1711X-REEN li ..,.ul. =, fiafitHi EAM c14"a ' : • ;a@to r
Agricultural c�
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL�Municipal/Public ft ft. is
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single)
ft. ft. to
Dlndustrial/Commercial Residential Water Supply(shared)
te:G•ROIII`. ' .
nImQation xct'.." u...._,?•_.,..Ff•�t,"A•x,,3;..d�-•z.. ✓._.. v ,.e5``:t 3 «x.�' 'E.a'?E
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 20 ft
• Bariod Hope plug Pour
CiMonitoring E3Recovery ft. ft
Injection Well:
infer Recharge ft. ft.
A
qGroundwater Remediation
Aquifer Storage and Recovery Salinity Barrier -sFROM D/G `` 1'A fMATERIAL P„ .. ,a.MPLACE ,ENT ME HO t4IM
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft: ft.
DGeothermal(Closed Loop) Tracer r'
30.tDItILT:INGXOW{aitack,adtt[tional"s)reets`3i4tieceaarXAiMrx naW«fMRsr�>:l
FROM TO
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
V Jfr. E CR IO t��ardncss,solUrock type,grain size.etc.)
ft. `S
• 4.Date Well(s)Completed:a-'�'ay Well ID# LO/, `�6 1s-ft- ?0 fr. /�
5a.,Weelll Location: f �f 3Qft. c[-Jr-ft- Woad /45di/
A kk' #id 1`1r'4ecRr4ve S�� alis-ft 6rf is fFo�!
Facility/Owner N eFacility ) fL f �+ �\
fl ID#`(ifapeplicable)
aC'ititri3"44
Physical Address,City,and Zip ft ft R (< i Q $ '
' °County Parcel
Cd— �!/V�+0�7 vil 4 4 (Xia
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IR :i ii?r':Q2 1? ^ Sc!,�f o-y(iPrs
(if well field,one lat/long is sufficient) 22.Certificati DL rQ'
N W 1
a- 1— LI
6.Is(are)the well(s)JPennanent or Temporary Signa erti ed We ontract r 6 Date
By s•ning this form,1 hereby certi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EiNo wit 1SA NCAC 02C.0100 or 1SA 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:dof(ft) 24a. For All Wells: Submit this form within 30 days completion of well
For multiple wells list all depths if tfferent(example-3�200'and 2@a 100') p
construction to the following:
10.Static water level below top of casing:40 If water level is above casing,use"+ (ft) Division of Water Resources,Information Processing Unit,
, 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: hi addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a d GPO Method of test: Air lift 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/o Tabs completion of well construction to the!county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016