GW1--01850_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: �s # o 1,+ 'i
1.Well Contractor Information:
Joseph Bailey 14vATE1taN y
. y.. fix: 11 4 ,.1 - .
Well Contractor Name FROM TO DESCRIPTION
3271-A �S, ft' I S ft. .Ss' "/ c6/ Z fe
NC Well Contractor Certification Number ,A9 f t AZI.fr'm ,S,4 i/ / &2 s Z(#C
I: OUXER=CASINf s( r:m"Itt=2hfeiLwilisji010 apFlii#(eja s
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
fit gi f ft 1 in.
Company Name Q 6 25 SDR 21 PVC
' 0�3— �i3S�v 0 A mg II DIAMETER Hl l . 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. in.
Water Supply Well: gi7ZCREi S . ,� ...M*;MI r A = "' -.
®Agricultural FROM TO DIAMETER SLOT SIZE THICKNESST MATERIAL
�Municipal/Public ft. ft. 'in
°Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
fit fit in.
OlndustriaVCommercial Residential Water Supply(shared)
ri$roitO
Irrigation 1IT .s a srM Infi r�, k r�TW: r
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 'R,A` ft wA �Ay
OCI Bariod Hope plug Pour o(/
°Monitoring °Recovery ft. ft
Injection Well:
q °Goffer Recharge ft ft A
roundwater Reniediation
Aquifer Storage and Recovery Salinity Barrier FROM GiT.S L.PAM if�applleiih re) y t= ; ,� } =U
FROM TO MATERIAL EMPLACEMENT METHOD
. °Aquifer Test DStormwater Drainage ft. ft.
®Experimental Technology °Subsidence Control ft ft
°Geothermal(Closed Loop) °Tracer ?'ZO:D111Ll';11�t t}G'irffic}$ddtraonitl�glteetsifie
Geothermal(Heating/Cooling Return) FROM TO DESCRIPT N(color, artiness,soiVrock
( g/ g Other(explain under#21 Remarks) q type,grain size,etc.)
l-3�Q?t/ ter Oft /v � f��Sol''/
4.Date Well(s)Completed: Well ID# D f. ft /?4 j!1 id,
Z.
sit.5a.Well�L/ocationN:�y� Flex
(� � ft. y� /{�
/�r/1 1 4r^tii� / l ex /a S� GU ft. 9�ft v : sdi T
Facility/Owneritj�� Name / Facility ID#(if applicable) )� y fit 6 d�i Ree
//f Rataer ��ieI,d i`'O�Jdif4/f 14 c2.00! ft ft. '9�i (�itC
Physical Addr ss,C' ,and Zip ft ft
Zj ®/ fit:REMAi 3.g.,,—m ;. , �s
County Parcel Identification No.(PIN) - •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MPI'{ G 2074
(if well field,one lat/long is sufficient)
22.Certification:
N W i '..ri ta:t. 1 a•"•-;.Atsv a l/i ® -
DWQ,3 G c.
6.Is(are)the well(s)ElPermanent or °Temporary Si of ifie e i C or ; Date
B signing this form,I here ertify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or E4No with ISA NCAC 02C.0100 o ISA 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 details. You may also;attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
/�G�-F SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ``�� fit.) For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2@100) ( ons c
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 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) coiAra 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 county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016