GW1--01871_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: • .
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1.Well Contractor Information:
Joseph Bailey •i4wA�'ERztNEs :. k,= , „a
Well Contractor Name FROM TO 1 I,..DESCRIPTION
3271-A a0 ft* c2 ft. ; /no`j7ki% jle_
NC Well Contractor Certification Number 420 ft. ! 6p ft. 5 ./� 4 67 `
15 OUTER:CC9ASINPG(formulti-casedtvells)`ORLINER'(ifap licable)=v .
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS g MATERIAL
® ft.. 5 I ft. g 25 in' SDR 21 PVC
Company Name
SA(t � �� f 6/ '16:?INNRRR IG ORTUBING'(keothermalclosed-latp):,. _`�, . *L ...1
2.Well Construction Permit#: ' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. D. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: Y7.t5GREEN ,; ,m ;: �;:wr .1 T, ,.•T
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft. ft. in.
©Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) ft ft. in. •
QIndustrial/Commercial Residential Water Supply(shared) ;1r3 iGROUT. r s
Irrigation w„ -.,n S e , FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: '•'-" = • i ft. ft.
�C.���P. �, l 20 Bariod Hope plug Pour '�? ���j�
Monitoring Recovery ri ft. ft. '
Injection Well: MAR 2 G 2024 ft. ft.
Aquifer Recharge OGroundwater Remediation
A uifer Storage and Recoveryp�Salina `BamC�• :r-"'�^'7'�"A k r R '9::SAND/GRt1VEL PACIC'(dappIIpble) :;; ,,t ` _,, ss 1
q g F.V t'' FROM TO MATERIAL EMPLACEMENT METHOD
QAquifer Test QStormwater Drainage'03, ft. ft.
©Experimental Technology 0Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer i20 DRILLING LOG'(attaehaiididooslsheels`.ifnecessary): ..,. .r,:: , .:. e°:
DGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
�y /J ® ft. r ft: f e So
4.Date Well(s)Completed: c2 M�a4/ Well ID# 4/4 tc ft. f (ft. 1�� 8,, G
5a.Well Location: ft. ( ft 4q3l (ry(�/'j ,
ray,'
ay-,rf �®/4'�f 0°N0e r
ft. ® ft. YE/ BSI Bowl orm. 1
Facility/OwnerfName Jl Facility ID#(if applicable) ft. 4 'ft: eji/J $ ex�� 1Trrssr
S6210 Arbor (11007 A 25429 W 'ft. l e ri`L' 7,kxk,
Physical Address,City,and Zip ft. .I ft
IV��4VR Qr✓V� co_ t21;'ItEhIARKS-;' . ., ... .„' ,.?p+a ..,,x.;:' >t.•....a r,N
County Parcel Identification No.(PIN) r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one 1at/long is sufficient) 22.Certifi 'on:
N W
6.Is(are)the well(s)OPermanent or Temporary o c fi Contractor Da
signing th.form,I hereby ce,!, that the wells)was( re)constructed in accordance.
7.Is this a repair to an existing well: DYes or EnNo wu/r/SA NCAC 01C.0100 or Ice
A CAC 02C.0100 Well Construction Standards and Arai 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#2l 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,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: °� (fh) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(flerent(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 Iniection Wells: In addition to sending the form to the address in 24a:
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: '
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program, '
FOR WATER SUPPLY WELLSB ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4A1 Method of test: Air lift 24c.For Water Supply&Infection 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 2-22-2010