GW1--03109_Well Construction - GW1_20240522

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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 13cat ; r33 ft .Sins//pG&/'ern C
3 Ooft• 3agr ft k � "rfa ie7ttfric
NC Well Contractor Certification Number 15.OUTER CASING{for mull wells)OR LINER(if a le)
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 6 a 'ft 6 1/4 in' SDR-21 PVC
Company Name 2.Well Construction Permit#:
(way /�C- 1/ 953 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.1,7C.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 ❑Mu cipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑lndustrial/Comrnercial ❑Residential Water Supply(shared) IS.GROUT
CI Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 ft Bentonite Pour 4 44f,4.
❑Monitoring ❑Recovery ft 1 ft
injection Well: -
.-,
ft ft
❑Aquifer Recharge ❑Groundwater Rcmediation •,'-- • ' •`;.4 .•, �' t
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPIMCSItiE METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft , L, 4 4 eth.4
❑Experimental Technology ❑Subsidence Control ft ft. I ,
I Syr r5:.z.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets ff necessary) (Yf'r'`. " ud
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRiPfIQN(color.ha ,ness soil/rvck type grin size etc.)
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4.Date Well(s)Completed: y/4/p199 0 ft /a ft gedi50r
Well iD# 'g ft 3 C ft /ark/rl i°'"
5a.Well Location: y?6 f. 4/ ft. ;Jr,v,/ jf/fabr Ft6h Ho vSe y -7-, rJ� ft tabu/
6 S ca fdi
Facility/Owner Namc Facility ID#(if applicable) 5C ,t• •J 0 ft ieQ J Q G/`
/60 fifer qd film irsdi1//, Nc aim' po ft y .6.1 T!l1000"' ocfc
Physical Adj ens.City,and Zip ft ft
C /' "` 1/ 1-,/',cY j 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
N W •
W iec29
6,is(are)the well(s): anent or ❑Temporan' Sign of Ce red I Con cto Dat�
Br, sing this form.1 hereby ce i that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o /S NCAC 02C.0100 or ISA Al AC 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 n his record has been provided to the well owner.
repair under 2I 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 1 GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
✓) 24.SUBMITTAL INSTRUCTIONS
3 9
9.Total well depth below land surface: 5 ft.
For multiple wells list all depths if di (example-3@a 200'and 2@100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40
A) 24a. For All Wells: Original form to Division of Water Resources (DWR).
If neater level is above casing,use"+'. ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 �1$ (in.) 24b. For injection Wells: Copy to DWR,Underground Injection Control(iUC)
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(gpm) L7l i`/ Method of test:f Air Lift Pennit Program, 1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018