GW1--01834_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Joseph Bailey r14 WATER$ONEs y ,< :, _ .512. iegt., ,; ,w, v- , .,..N.� , .w.;
Well Contractor Name FROM TO DESCRIPTION
3271-A l'/S�D ft' lc/ ft' .S'ma//(�% 47U/r Zt1�
9 I
NC Well Contractor Certification Number p •�t 15:OUTE t Sp
/11 4# �C ��/ O
R�CASING(form>i -caeedivells)ORnfNER(ffap"Hca le). .- ._.? `
B&K Well Drilling Inc FROM TO DIAMETER 6THCCKNESS g MATERIAL
Company Name 0
ft ft 6.25 is tSDR 21 PVC
fj � .:iI6LINNERCASING:ORTVBING(geothei•maiciosed=l6op) .._. .2,„.;, sh
2.Well Construction Permit#: CUP' '''3 S'4 FROM TO DIAMETER 'THICKNESS MATERIAL •
���List all applicable well construction permits(i.e.UIC,County, fate,Variance,etc.) ft. ft. in. !
3.Well Use(check well use): ft. ft. in.
Water Supply Well: i17 SCREEW.,. .. .,..., .; ;:., F.t,:a;c ,. ,�, .i ;x i--t�•s .. ."
FROM TO DIAMETER SLOT,SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. is
Industrial/Commercial Residential Water Supply(shared) g'^GROUT i{f
Irrigation --FR TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: •t - ' \ ,gip 20 Badod Hope plug Pour
Monitoring DRecovery L ft. ft.
Injection Well: MAR 2 ` Z0 M ft. ft.
ID Aquifer Recharge oGroundwater Rcmcdiation
Aquifer Storage and Recovery Salinity B 'er ,a `^7�'rrt" /GRAVEL4'ACIC(ifapplicable),_,:r r ,-,�:,S. t,y: f ;, _,.,,
yy,,fer s 4-ROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ilC''1. ft. ft.
BExperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer iMBRILLINGO LOG'(attich additional sheets lfaecessir i . .-g.Z A,7<
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRI ION(color,hardness,solUrock type,grain size,etc.)
rd ryry 6 ft. c ft. e do 11
4.Date Well(s)Completed:N Jtr/eat'q Well ID# L.Tt 5 ft. f.f" ft, yeliosa Siz .Q,1
5a.Well Location: if ft.ft. a ft. �j$Q 3 //
ft. /Dor 6r4.9f f �Oi;/< O?del
Facility/Owner Name Facility ID#(if applicable) ft ft.
Physical Address,City,and Zip ft. ft. !
Re Cog, j�f5' ,215;R$I�IARICS _..3 ;:�j ..,,,„ a a ,, ,,,, ......................................�
I ,
County Parcel Identification No.(PIN) At/P449;Dq !`oG I( G is 44f. e $ /l{,r 1 U
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ��Y xesf. G/ ,11' Qum'S/G
(if well field,one lat/long is sufficient) 22.Certification: ati
r
l
N W
1 /g
6.Is(are)the well(s)E1Permanent or Temporary , ... ,
natur of Cc ed WV,'ontractor ate
•
ty signing this form,1 herebye certibi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or jNo with 15.4 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 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 i.
9.Total well depth below land surface: ®./I/ P (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@201'at 2@100') construction to the following: :
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 6 1/8 Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:Air lift 24c.For Water Supply&Injection 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 couiityl health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ( Revised 2-22-2016
II .