GW1--04256_Well Construction - GW1_20240719

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 v r` '/e� fit- mej ore
v 1 V fL !�el _6/we �L
NC Well Contractor Certification Number fL v
15.OUTER CASING for mNtia axed wells OR LINER if a
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
rI. L 61/4 in. ISDR-21 PVC
Company Name f 60/
16.INNER C. ORTUBLNG
2.Weil COOStrDCtlOn Permit#: FROM TO DIAMETER THICKNESS MATERIAL
L}a all applicable well constructimi permlLs(i.e. 71C.County,State. Variance,etc.) ft. f6 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMuni ipal/Public fL ft. in.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) R ft. in.
❑Industrial/Commercial OResidential Water Supply(shared) 1S.GROUT
❑IT ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Bentonite Pour30
❑Monitoring ❑Recovery fL fL -
Injection Weil:
ft. fL
❑Aquifer Recharge ❑Groundwater Rcinediation
19,SAND/GRAVEL PACK ifa ble
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMP MF.THOD
❑Aquifer Test ❑Stormwater Drainage rL fL
❑Experimental Technology ❑Subsidence Control fL iL "'"'
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional spats K
❑Geothermal(Hcating/CoOling Retum) ❑Other(explain under#21 Remarks) FROM To DESCR ON(color,hardnm,soit1rock a n size,etc.)
fL tt C O/
4.Date Well(s)Completed: Well iD# fL / ft iron
Sa.`lWell Location: 0 fL to fL " G
.3 0 fL tpr fL f ail Jaen •�4 4'
Facility/OwncrNann Facility ID#(ifapplicable) t4 0 fG 1- i G ./ 41
fL iL
Physical Address,City,and Zip ft. fL
Aki to. Da.3 -o�lf as 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certifl ation•
N W
6.is(are)the well(s): manent or ❑Temporan' �"i, 7:
f c fied ell Con ct Date
his form. the nrll(s)x•as(were)constructed in accordance with
7.is this a repair to an ezistlng well: ❑Yes of o NCAC 02C.U100 or 1SA N 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 provided to the tsrll owner
repair under=21 remarks secunn 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-I is needed. indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O S (ft.)
For multiple trells list all depths ifdifferent(example-3@a 200'and 2L100') Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing:40 24a. For All Wells: Original form to Division of Watcr Resources (DWR),
lftraterlevel is above casing.use-' (ft) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/1 8 (in.) 24b. For injection Wells:Copy to DWR,Underground injection Control(1UC)
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
13a.Yield(gpm) o Method of test:
Air Lift Perm Program, 1611 MSC,Raleigh,NC 27699-161 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