GW1--01844_Well Construction - GW1_20240322

ilj
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.'Well Contractor Information:
Joseph Bailey :z14r wya.LR'LflNF.S, `t FX -1
FROM TO DESC I'l0 We1lContractorName 5t ft- ft- /? Te3271-A Jere
ft. ft
NC Well Contractor Certification Number I
'tS OIITEIf ASING'(formNttiaiWegs):QIt MATERIALTHICKNESS
Company Name 0 ft N ft 6.25 : 1°• SDR 21 PVC.
�_ (l n /�1/7 J I FROM
R5';IlVNEItG I1!IC:.UIa[ I)BIAM eo -
W QW� (/77tz tltermaCctaset ltaujl}3< MATERIAL
,s. .,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in:
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 72SCRF,EN .FI. sl i, « I: ="` , :
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single)
Industrial/Commercial Water Supply(shared)
ft ft m
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. Eartod Hope plug Pour 9 a Q4 6s/P
Monitoring Recovery ft. ft. I J
Injection Well:
uifer Recharge ft ft
A
qGroundwater Remediation
,I9 gAND/GRA3 .PAOKi(ILapplca"bTe}„ w,.ter-}. , ;... - ,.' ;t v
Aquifer Storage and Recovery of Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStomtwater Drainage ft. ft
Experimental Technology 0 Subsidence Control ft ft
Geothermal(Closed Loop) Tracer
l0TiRIL`'LIL9GItf3G(atfacTiad'tlit2QriZsficetil£aecessary)7M, y, —�,��.a
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
n1 EL
/O ft. /'
Or /�'`a (/ Soy4.Date Wells)Completed: / tiyell `� ft. O^o ft.
S Od
5a.Well Location: go ft fj(ft. f t// awl5dfs�1
S4 han, /'1,c6 e1 Ai// Ad.( Sept )�0 I So/I
Facility/Owner Name Facility ID#(if applicable) /U ft /J f`' ,P ii /-1 j Roc
1 '13 /?r4birtfN�j,Per,7 /YG. ,22(0 � t e2 6Sr 4`Tfr 4a c/c
Physical Address,City,and Zip
t ft. ft
7 G /A CAL !D` 4 � �T«KlbIA/tRS..', i '. �r. fir Vi a� *74 4� �`„
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �':i.. (, A; ('
(if well field,one lat/long is sufficient) , e,C.—c�r t ay e �
22.Certification:
N W ' tt222024
27/4/If'
6.Is(are)the well(s) Permanent or Temporary Si t e of i a ell Con_ ctor_,, 1 zp to
Coil!.
ii if s::;.•.:.it , . :'•�:e.741,1 jig;,
signing t is form,I her cert fy that,Y�t 'we(Z(s) yas(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EiNo with 1SA NCAC 02C.0100 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
r SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 205 (ft-) 24a. For All Wells: Submit this form within 30 da
For multiple wells list all depths?I-different(example-3@200'and 2@100') yS of completion of well
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 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
Division of Water Resources,Underground Injection Control Program, _
FOR WATER SUPPLY/WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
!J
13a.Yield(gpm) Olti Method of test: Air lift 24c.For Water Supply&Injection'Wells: In addition to sending the form to
type:
Chlor Tabs 1 1/0 Tabs
13b.
Disinfectionthe address(es) above, also submit one copy of this form within 30 days of
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
1