GW1--03113_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 1lf/ft. 1,i?.ft' Swjs / / 'c'T},re.-2eye
NC Well Contractor Certification Number a ' AR . �dd F ` e -e
15.OUTER CASING(for multi-cased wells)OR.LINER(if a licalde)
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. qk ft. 6 1/4 1n. SDR-21 PVC
Company Name /'/ �//� ��J/ y�jj�j/ 16.INNER CASING OR TUBING(geothermal elesed-loop)
2.Well Construction Permit#:D�"`r P.'11 t� / 7i(ff FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State.Variance.etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in. 1
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici lie ft. ft. in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD.9Q &AMOUNT
Non-Water Supply Well: 0 It 20 ft Bentonite Pour l')T 1415 HA.
❑Monitoring ❑Recovery ft. I it
injection Well: .-. .
ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK(if applicable) •-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACFAN ENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft ,', /U -1
❑Experimental Technology ❑Subsidence Control ft ft.
!r'.. • s .. ..r,:
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necesaary) r v r; ~.
FROM 1 TO DESCRIPTION(color,hardness,soil/rock type,grain Size,kte.1'
❑Geothermal(Hcating/Cooling Rctum) ❑Other(explain under#21 Remarks)
�/ / //� 0 ft G1 ft LG{ 5 ail
4.Date Well(s)Completed: 3����7 Well iD# {// '7�� ft I jçft.
r/ tr�/�y , �Sa.We Location: !!! ft . / 4 , , _,,
oho AA/gall/ L ACT 3S ft. 40� ft !• S awl Ara•,l 7��, j s
Facility/Owner NAn
a pity lD#(if applicable) U/� ft. C ft k-11/tco2 T&hd i�r,�leooi 6hti�AlG 5r. 33,f` G d /( ��
Physical.Address,City,and Zip �'a('�i 5ft.1 vKi ^�I
.rtde// e6_ 1/421/r 2'.°Q91/ �21.�yRREMARKS
County Parcel Identification No.(PiN) Lie !'7/ a 0 Pi 1Ce Apr Cc$571. I
b l+�d Sat vc f� IP 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 19" [llar a AIcL�a i�
(if well field,one lat/long is sufficient) 22.Certification: • 01 07IA)`/5 tC
N W v? �
6.Is(are)the well(s): anent or ❑Temporary i tore of rtified ell Contracto O e /
signing this form.I hereby c rti that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or SA NCAC 02C.0100 or/SA AC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known well construction information and explain the nature of the of this record has been pror•i to the well owner.
repair under+2!remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-1 is needed. indicate TOTAL NUMBER of wells (add'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
�j 24.SUBMITTAL INSTRUCTIONS
,..)
9.Total well depth below land surface: a (ft.)
For multiple wells list all depths if d fferent(cxnmple-3@200'and 2L1oo') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR).
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 ��$ (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
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push.etc.) 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) (jre Method of test:
Air Lift Permit Program, 1611 MSC,Raleigh,NC 27699-1611
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