GW1--01846_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Joseph Bailey
tivivattraolissmawommurvimaimmaremmumezmiizm
Well Contractor Name FROM TO DESCRIPTION
3271-A aaso. 0?3 ft' SA'!0////+ �7r/'ezG�l►'e
NC Well Contractor Certification Number 2 v a. f t /'ego 4e��—
iTIK-OU7'ERCi 4G(Cor`htuii ."r-yt'eli'S'OItiibfl l>( .►ire)'u' :-B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0Company Name ft i 78ft. 6.25 1°• SDR 21 PVC
E/�l{/0�,3 moo` �, =�& 1, iiASIi GOR,TVmxay(ReotYerittal closaiAUbt}w�„r. Y t.±
2.Well Construction Permit#: 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. I ' in.
Water Supply Well: LIT.SCREED8� A tl,a . aWM4cn )ell H
A CllItUIaI FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) laResidential Water Supply(single)
ft ft in.
DIndustriaL/Commercial Residential Water Supply(shared)
u IL,G1ZOVAl'..�2t rq*.:=`1 .m e a ,rx tiva,n r+9"s�'Mit1'.'40t�'zPIi.,'�*PtiiiVI rAVI
°Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 ft Bariod Hope plug Pour If 45,2 EA
Monitoring °Recovery • ft. ft
Injection Well:
ft ft.Aquifer Recharge °Groundwater Remediation
A uifer Storage and RecoveryOd9-AAN IGRTO (iATERIAL e,.. ";AW MP E,tit'Af H '. g:q g °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft
Experimental Technology E3Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer DRII IOI fib(attae"h`itddt iu iQis$ectsine R
FROM TO DESCRI ON color harddn soil/rock I � k
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) O `� nttype,grain sire,etc.)
l 0 ft It. R .7 ///
4.Date Well(s)Completed:t1/ •/a Well ID#44TL 3't I� /[eft. /��, ,,�f"asO f
5a.Well Location: 4i t. ,01 it. CY#IW e;'„, 7 sei
7. /YMR5 W AV oP 2.4kelf'w1/4i s71fis 100 f 3o f t Fria /3to wf S $i4 .
Facility/ er Name Facility ID#(if applicable) 94ft• / f- tQ" //
ha'1 ;. de.lrr.NGdgali- 1Grt• /yam 1.1- s�Y
Physical Address,City,and Zip jfr. a/_) o/
1 ih lO//7 . 67 9,ato, ;zi.,JiJEt41AA. , aria i r N i twi F<
County Parcel Identification No.(PIN) T,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C:ti O 4 " 8 e. �
(if well field,one lat/long is sufficient) tt
22.Certific 'on:
N W MAR 2 G 2GZ4
� x. �f
6.Is(are)the well(s)OPermanent or Temporary signs o ea' ed el kw
ntractot' ;t e.: •^Av''''"1}ate
By s'fling this form,I hereby cet that the weft(%was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or EiNo with ISA 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 I GW-I 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: 94 5-4 (It-) 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@I00)
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 Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For Infection 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
const ruction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 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) 20&Pei 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.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016
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