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