GW1--03111_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: j
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
3271-A 9S ft tqb ft. SJrtt</ %i-eAwe
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable) •
B & K Well Drilling Inc FROM I TO DIAMETER THICKNESS MATERIAL
Ot ft. 73-1 ft 6 1/4 in• SDR-21 PVC
Company Name
D 0 ?p�1� 16.INNER CASING OR TUBING(geothermal closed-loop),
2.Well Construction Permit# .]7 Az FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC, ounrv,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 ❑Munic blic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) srdential Water Supply(single) ft ft in.
❑Industrial/Commercial OResidential Water Supply(shared) ig.GROUT
❑irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Pour r' , 10
❑Monitoring ❑Recovery ft ft
injection Well: _
ft. ft
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK(if applicable) 1• '".-- :" k-.r '' 1
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHODn
❑Aquifer Test ❑Stormwater Drainage ft i ft 1;f/i''r 2 G ?U?T
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets lfue coorrg')">(` ''t `. ! �'}
FROM TO DESCRIPTION(color,hardness,soil/rock type;RMn aae,'5t.)
❑Geothermal(Heating/Cooling
�/�Q`j/�m� �/❑Other(explain under#21
Remarks) D ft /eft 5O//
4.Date Well(s)Completed: / 3/ 47 Well iD# -/ 4 1- /5'ft Qcft 0444ri1'f5a.WellLocation: H« lJ Jfl,lr$
3l it �J rt 1/ 0v� �0 /54
E/i3,bfj O[&'N// 11- Dorm f. it .lrft s.tr/i?mir/ ff►sd,,„
Facility/Owner Namc Facility TD#(if ap icable) /_�ft. Q�ft So /zr''nDL/� f6 fr/
33C - Hot5194 & 7 o'1 i ri M. /4G (6Q ° t �`(a7(1sr G„0„" .7- E•t 11�,00
Physical Address.City,and Zip �J fL ft
�7:feJ ll ea Li s7o .a y-�/0/) ft
Counry Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: �� �j'
N W h tgd$'�f/
-e*I2V-.
6.Is(are)the well(s): rmanent or ❑Temporary Sign re of feed Well Contracc D
By signing this form.I hereby certibr that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Vier".............-- ISA NCAC 02C.0100 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'21 remarks section or on the back of thLs 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'Sec Over'its Remarks Box).You may also attach additional pages if necessary.
drilled:
/aesi 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft,)
For multiple wells list all depths ifdi/ferent(example-3(a3100'and 2(�/00') 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),
If water level is above casing.use"+' ( ) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b. For Injection Wells: Copy to DWR,Underground Injection Control(iUC)
11.Borehole diameter: 6 1/1 8 (in.)
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
I 4101
� Air Lift Permit Program, 1611 MSC,Raleigh,NC 27699-1 61 1
13a.Yield(gpm) X ' Method of test:
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Recourccs Revised 6-6-2018