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HomeMy WebLinkAboutGW1--03108_Well Construction - GW1_20240522 WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: 1.Well Contractor Information: Joseph Bailey 14.WATER ZONES Well Contractor Name FROM TO DESCRIPTION 3271-A 16Oft �SdZ ft sing( ji-,T:r- 2 (Ir. ,jq1 ft. p74 Frill;� 17dritC NC Well Contractor Certification Number 15.OUTER CASING(for multi-used wells)OR LINER(if a licable) 1 B & K Well Drilling Inc FROM i TO DIAMETER THICKNESS MATERIAL ft. / ft 61/4 in- SDR-21 PVC Company Name / /( �� �Qa _ 16.INNER CASING OR TUBING(geothermal closed-loop) . 2-Well Construction Permit#: 05 C/i I ie.) FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.GIC.County.State. Variance.etc.) ft. ft in. 3.Well Use(check well use): ft ft. in. Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL :Agricultural ❑Mun . blic ft. ft in, OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in ❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&A.MOpUNT Non-Water Supply Well: 0 ft 20 ft Bentonite Pour `(�JsiS•Nir' ❑Monitoring ❑Recovery ft ft. injection Well: f :Aquifer Recharge ❑Groundwater Rcmediation ft. ft 19.SAND/GRAVEL PACK(if applicable) " - . ' :Aquifer Storage and Recovery ❑Salinity Ban-ier FROM TO i MATERIAL EMP4.ACFMF.NT METHOD - ❑Aquifer Test ❑Stormwater Drainage ft ft. ;! :Experimental Technology ❑Subsidence Control ft. ft. OGeothermal(Closed Loop) ❑Tracer `�' 20.DRILLING LOG(attach additional sheets ff necmaaarT) y., ,,.: a r:.0 FROM TO DESCRIPTION(color, ardness,witirotkl}'pk graie(bra,etc.)OGeothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) a e r)� �� ft I ft �c 5 a/ - 4.Date Well(s)Completed: +//O1� U Well iD# (p/ I v ft 1c ft jar a`Ow4 O/r 5a�.Well /L/o/cation: /) r J5 ft. I)5ft �•Y//fir MIS/ .S e t fL 417 5..! Facility/Owner Name Facility IDe(if applicable) 94 ft. / /oft me❑ t// RQ`k( /59 ,39//yC45//eAd /004( 11/€1✓C,a4�cf I/O ft fo�ft r1 Roc,c Physical A dress,City, nd Zip ft. ft 11 ea, iii,gi- 9 3 a2 4 21.REMARKS • A County Parcel Identification No.(PiN) L/,/G r�O6'7C I /c 35) ,,ip'///`,* 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: £,'47 r 209 C ' 7 40 - T 7l .50/0//Z Arc 1 (if well field,one'at/long is sufficient) 22.Certification: / N W / d , ' , 4///00,7f 6.is(are)the well(s): l rmanent or ❑Temporary Signa ofC• fled Well Cont. Date Br. fling this form.I hereby ce that the well(s)was(were)constricted in accordance with 7.is this a repair to an existing well: ❑Yes or 0 ISA NCAC 02C.0700 or ISA NCAC 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.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 construction info construction,only I GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: PC l 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: (ft.) For multiple wells list all depths it-different(example-3(200'and 2@I00') 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). /f water level is above casing.use"+" information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 11.Borehole diameter 6 1/18 (in.) 24b.For Injection Wells:Copy to DWR,Underground injection Control(TUC) 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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 13a.Yield(Wm) Permit Program,1611 MSC,Raleigh,NC 27699-1611 Method of test:Air Lift 13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2011