GW1--03117_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
I.Well Contractor Information:
Joseph Bailey 14_WATER ZONES
Wet Contractor Name FROM TO DESCRIPTION
3271-A 1.30 fL /1)," fire/ftrahe Ave
ro
NC Well Contractor Certification Number 9 VI- Gt�ft /-le `ki fe A4-e
15.OUTER CASING.(far 1/aani-cased• wells)OR LDIER(if a - )
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
d1 ft. �O1ft• 61/4 intSDR-21 PVC
Company Name `// It DINER CASING OR TUBING(geothermsT:d 7eop)
2.Well Construction Permit#: E�if/ - a5/�J�//(p FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ce.UIC,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 ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) sikesigential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&A oUNT
Non-Water Supply Well: 0 ft. 20 ft. Bentonite Pour /`4,
❑Monitoring ORecovery ft ft.
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft
❑A uifcr Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK{tf'apptinble) .. .14g,x I� t :
q g ty FROM TO M:ITERIAl. EMPI&AaMENf 11iE114011
❑Aquifer Test ❑Stormwater Drainage ft ft 1
1/luY L J e iU?4
❑Experimental Technology ❑Subsidence Control ft. ft
1r.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attack additional sheets;i nearmary; t, :y'•i WI;jr y
FROM TO DESCRIPTION(color hardness,soitirt[ck type,R/lpdee,etc.)
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) i-:
4.Date Well(s)Completed:3/c/ y Well ID# 2,0 1p. z1 d ft idr.,„i„"7 !a1.
5a.Well Location:
Tit e" Q ft. 3 ft. R4i, B r+,s yr ,jot 1
be5 /r1
, llev -�ite" Si"! Pori a 30 fc . q fL v(z_v!....4.5.11.04,,,....../
a cility/Owner Name Facility M#(if applicable) 4/ . f4ft •I"� j e.co,c
&Uc7cL ie k4,i Sri///G 04/ % 7 ft.ft. ft.
Physical Address,City,an/Zip // /_ ft
L,iitn co_ /o0 4 a 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22.Certifi 'on: /
/N W /• , / 0 00 t
if eie
l%r-it-2- ---
6.is(are)the well(s): IP rmanent or ❑Temporary ure of Cert f ed e Contra.or e
B signing this can.I hereby certi'that e well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ler. 5A NCAC 02C.0100 or ISA NCA. 0 .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 fthit record has been provided to the well owner.
repair under.11 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !-ic/ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For nudtiple wells list all depths if different(example-3@a 200'and 2@ 100')
10.Static water level below top of casing:40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR).
If eater(eyel is above casing,use'•+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6 /18 (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
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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
/, Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
V
13a.Yield(gpm) 04 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 Resources Revised 6-6-2018