GW1--01851_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
Joseph Bailey a:+ ATERZO Kt -
Well Contractor Name FROM TO DESCRISTION
3271-A /a D ft" /2 4i ft" /rk feacroom wee
ft. ft.
NC Well Contractor Certification Number
B&K Well Drilling Inc FROM ER.CAft111 (rhemnl ETER 17€; S --' z y -:-
FROM TO DIAMETER THICKNESS MATERIAL
Company Name j� ft' �v ft' 6 25 ' in. SDR 21 PVC
�„�_A�� r ?I�^ 1:611N v'R`G��YASVI"'GTOR`hTUB 111afOotfielnCB!clICKNE 'jam A A 47-2.Well Construction Permit#:(`'Y{f(f/ J! 42 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: 71SCREENaI:< ''x. :. ... '; •�R z ?A,l s ,.,.. i `.
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) EPesidential Water Supply(single)
ft. ft m
Industrial/Commercial DResidential Water Supply(shared) _
S G120U1 s, ?a` 5: � .en, ray €
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft- 20 Barbel /6 LJ) , H/l
Hope plug Pour /V
Monitoring Recovery ft. ft. !
Injection Well:
Aquifer Recharge °Groundwater Remediation ft ft
Aquifer Storage and Recovery Salinity Barrier 49z SA1YD7GRAY.EI;<PACKdflit lie blejr VAM4 r. _,_,,, ,, .
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. 1
Experimental Technology 01Subsidence Control ft.
ft.
Geothermal(Closed Loop) °Tracer
F.v9' .f20:;D1tIY;'LliVG2iDGOt'nfchar10i7ieiial+streetiif'IIrassa�j 'a- •W4UR; '��,-:
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION``(color,r,hardness,sailfrock type,grain size,etc.)
.t. ft. ft Red 50/
4.Date Well(s)Completed: i/ii ay Well m# ft. ,„?a fr• Sall
5a.Well Location: a 0 ft. q(ft. fail/ .a.,7 sal/
LK rilphef £it/�r)5 fAvsir°- £15,frt.
•5( ft. iter ft. 4 �,,46 soFacility/Owner ame Facility ID#(if applicable) A� P iL
/9y/ 7 iptert a_ flm, p, - ag)A eft. a_/a t. ,�,�,/� o
Physical Address,City,and Zip
J ft. fL G tG
County Parcel Identification No.(PIN) 't, ' ...i, to C L0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: PAPA 2 2 202Q
(if well field,one IaUlong is sufficient) 22.Certif ation: 6
p. a"
N W tfliLri ritai:'::it��-..--,4,:,. r:�! 17�7
DWOJZOG
6.Is(are)the well(s)JPermanent or °Temporary 7tusyerti Well o ctor n g this form,I h y certi That the well(s)was(were)constructe in accordance
7.Is this a repair to an existing well: DYes or EgNo SA NCAC 02C.01 or 15A 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 b n 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 1 GW-1 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: Of (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 00'and 2@I00)
construction to the following: j
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
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /37Am Method of test: Air lift 24c.For Water Supply&Iniectiton Wells: In addition to sending the form to
Chlor Tabs 1 1/o Tabs the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction t 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