GW1--01849_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey I4.WATER'ZONES r_,.
Well Contractor Name FROM TO DESCRIPTION
3271-A ,. 3r` 3 if0 ft kin?C ;/ ,��?�
ft ft.
NC Well Contractor Certification Number 15::OUTER CASING,yforitdnth•caseiksvells)OR L1NER(if.'ap lieable):
B & K Well Drilling Inc FROM T DIAMETER THICKNESS MATERIAL
9 ft. kI I ft 6 1/4 SDR-21 PVC
Company Name /��
lit /3 ® 061 FRON\ERGSSENGORTI)B AM R(geothermalclosed-loop)
2.Well Construction Permit#: FROM I TO i DIAMETER THICKNESS ''MATERIAL
List all applicable well construction permits(i.e.U1C,County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in,
"3.7 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mun /Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) esldential Water Supply(single) ft fc. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) „, •_
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft
20 IL Bentonite Pour '46S03119-
❑Monitoring ORecovery 'ft ft.
Injection Well: •
❑Aquifer Recharge ❑Groundwater Rcmcdiation ft. ft.
19:SAND/GRAVEL PACK(if applicable}
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD —
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft . ft
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LCa(attacit addittonaFsheetsif ike3ary) , ___ .
❑Geothermal(Heating/Cooling Return) ❑Ot cr(explain under#21 Remarks) FROM TO DESCRIPTTON(color,hardness soil/rock type grain size etc.)
IA ft !® f` 50// r
4.Date Well(s)Completed:1/�Bf c2g Well iD# /0 ft 0)61t a v/' 3' a, 1
5a.Well Location: r �y ft p ft* .1)//®Al/3 , i cr/r
Minced! Oval G hieme 0p--ft.
L aftA`� .��l f�/1l
Facility/Owneri�amc Facility ID#(if applicable) ft. 0 ft ed / deck
gq3� l�i�v lid- Zn' '/7 1,�c �g it it /( 4�
Physical Address,City,and Zip / ft. ft.
Ldieoln Ca,
d)fidIS r•;21:REMARKS
County Parcel identification No.(PiN) l 6 n��+1 'I ° .,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �'�'Li'L.Y, ,�
(ifwcll field,one lat/long is sufficient)
22.Certif lion: AR 2 2 2024
N W ^•
sy t���
n tore of nu e I Con ` i+ri fur.:Z :.''..7. -� •:�
6.is(are)the well(s): ermanent or ❑Temporary g EAGii.^1,--�,Gr�. I.Dat
t,G'J Jt:
'signing this form.I hereh,ce fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or f iSA NCAC 02C.0100 or IS CAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 65 (ft.) 1
For nuthiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR).
I(wnrer•level is above casing,use"2-•• information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 1i (in.) 24b.For Injection Wells:!Copy to DWR,Underground injection Control(NC)Program,1636 MSC,Raleigh;NC 27699-1636
12.Well construction method:Air Rotary
(i.e.auger,rotary,cable,direct push,etc.) , 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I
® 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield m c O �P� Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
(d`P ) Method of test:
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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