GW1--01842_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
1.Well Contractor Information:
Joseph Bailey
vI4.Ri`ATEttizoltT sum "
w x. wi F `m.v 1.,..; > a _',
FROM
Well Contractor Name `
TO DESCRIPTION -
3271-A //q() ft' /��ft. SMW f ilrr(i�drL%i-e
NC Well Contractor Certification Number ✓�N L 90Pt' I �7G
B&K Well Drilling Inc " `o c`Ais it, ov i M,f k
FROM TO DIAMETER THICKNESS MATERIAL
Company Name �j� 0 ft, 'ft' 6.25 `n SDR 21 PVC
2.Well Construction Permit#:��/"'�0 � � 96 i NN R to NG OR"TUBJNG(geothefsmal"ctosetrluojij, v^* ""
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: . ;7:1SCREEPi.. rt. iiaa fA . `V F,- , :x�- ..MX ' -__
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL~ `
Agricultural °Municipal/Public
ft ft. in.
°Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft ft in.
Dlndustrial/Commercial
Residential Water Supply(shared)
°Irrigation i8 GItOU .. _, x = = •,
• FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 ft / 4z5�/I2
Bariod Hope plug Pour v
Monitoring °Recovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation ft. ft.
s.Aquifer Storage and Recovery Et Salinity Barrier I4"S /G PA -(RapvOeible) ,,°- i1 _m y,u�
FROM TO MATERIAL HOD
Aquifer Test EMPLACEMENT METHOD
�StormwaterI)rainage ft. ft.
®Experimental Technology °Subsidence Control ft.
ft.
Geothermal(Closed Loop) Tracer
I(ORILIIIVCxlti(!O(nIfacl;idilfhiiiiii sVeWit eceasary)=_ " _
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FRO TO DESCRIPTION(coollloor,hardness,soil/rock type.gram size,etc.)
/ ft. p e) ft. J Ced S a
4.Date Well(s)Completed:)2/8JR3 Well ID# 14 ) /0 ft, Y0 ft, n
7 �!J fJ'?! �I�J O/
5a.Well Location: y 40 ft r-ft- (/l1 / �- /7S furl
5Uh9A/ /2o1Albr7 J4/e4 �i,./aid(. k .eft U ft. / et s s0 -1 '
Facility/Owner Name Facility ID#(if applicable) �0 ft. U ft (((I'I ci.,.r t
�ybJ L_ /j�G�'
1/�frlviu5 /urrnaCe I?ci go ft. 0 Crud/ ack
Physical Address,City,and Zip / ft. ft.
L./4;0 xi /v946$iy Ina/mums _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one lat/long is sufficient) ' f,
22.Certifcatio ' i�' �k 16�
�'_ ems. s
N W
6.Is are the wells 2 2 20Z4 eyv
( ) ()Permanent or TemporarySi Lure o Ce ifi ell Con for
y signing this form,1 here cv�lsefigtoolrxlel s)�w"a".ff e frconstructed in accordance
7.Is this a repair to an existing well: Yes. or No ith 15A NCAC 02C.0100 or ISA CAC 020),4i JWA 1 nstruction 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (5 (ft) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100
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,
6 1/81617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) I
24b.For Injection Wells: In 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: I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) crab.", Air lift
Method of test. 24c.For Water Supply&Injection Wells: In addition to sending the form to
ChlDr Tabs the address(es) above, also submit;one copy of this form within 30 days of
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13b.Disinfection type: Amount: 1 110 Tabs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I
Revised 2-22-2016