GW1--04252_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATERZONES
Well Contractor Name
FROM TO I DESCRtMON
3271-A L fL `y
ft fL
NC Well Contractor Certification Number -1S:OUTER CASING'.fern>epi-easedwdls OR,LVflM fla
pplikabli
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
fL 61/4 '" SDR-21 PVC
Company Name vv t
l% FROM ER L+iS ORTf7$7£T
2.Well Construction Permit#: F%� FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Counrv,State.Variance,etc.) fL fL in.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M ipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
❑Im anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O fL 20 fL Bentonite Pour
❑Monitoring ❑Recovery ft. fL
injection Well:
ft. ft -
❑Aquifcr Recharge ❑Groundwater Remcdiation t
1%SAND/GRAVEL PACK.tf ble° �- •- i .<.,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft. 5 2024
OExperimental Technology ❑Subsidence Control fL fL
❑Geothermal(Closed Loop) ❑Tracer f 20.DRII 1 HVG LOG tatbb addftionail❑Gcothcnnal(Heating/Cooling Return) TO DESCRIPTION(color,h "•4' in size,etc.) ❑Other(explain under#21 Remarks) fL fL
4.Date Well(s)Completed:��,/1� Well iD# LGf _ _fL t it fL fQSdrl
5a.Well Location: , u fL V fL Q1,
L(J4fi4 ✓ertffllt rcfrr fL a fL T
Facility/Owner Name Facility IT)#(ifapplicable) ft. /l ft. �'
I o" V L
Physic I Address,City,and Zip qq fL 1
—1' V H/�f � Q t 21.REMARKS
County Parcel identification A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 2 Certification'
N W
LIP
6.is(are)the well(s): anent or ❑Temporary Sllgningihisfiorjn.
a fCe red Contracto at
B /hereby certify at the wells)was(were)constructed in accordmrce with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ijthis 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 41 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-i is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
� 24.SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdifjereni(example- a)ffl 2@100') 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 1/1 H (in) 24b. For Iniection Wells: Copy to DWR,Underground Injection Control(TUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Alf 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
13a.Yield(gpm)� 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 6-6-2019