GW1--04268_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 D ft tt a
IL ft e �r �
NC Well Contractor Certification Number 15.OUTER SING formuNi cased wells OR LINER [a licabI
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 61/4 in. ISDR-21 JPVC
Company Name _ /
16.INNER CASING OR TUBING eothermai ciesed-loop)
2.Well Construction Permit#: FROM TO 1 DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e,CIC.C(Tunrv,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) LiResidential Water Supply(single) tt ft. in.
40rdustrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT
prmgation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite POUT
❑Monitoring ❑Recovery ft ft
injection Well: r ` ` '
fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MIATEUIXI. J. PLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 2U.DRILLINGLOG amchadd3tionalShlelesif
FROM TO DESCRIPTION(color,hardness,soiVrmli rain size,eta)
❑Gcothennal(Hcating/Coolin Retum) ❑Odtcr(explain under#21 Remarks) ft- ft Pt, )
4.Date Well(s)Completed: �✓ Well 1D# ft t rid
5a.Weelll Location: ft ft - ryv 07 d�
LC I�G � ft ft , �/✓� y
F
ac
ility/Owner Name Facility iD#(i applicable)
Physical Address,City,and Zip ft. ft
_a•'G I if/l G Oi a 21.REMARKS
County Parcel identi`ficcation No.WIN) I -K 41 U
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcil field,one lat/long is sufficient) 22.CAl
ertific lion•
N W
IP
4E 4=N---i I i*& -
6.Is(are)the well(s): Vr anent or ❑Temporary Sign re of ce fied Wel ontractor Date
�� Bl signing thi form.,here. certify th the wells)was(were)constnicred in accordance with
�'
7.is this a repair to an existing well: ❑Yes or V 15A.`'C.4C 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infarnation and explain the nature of the of this record has been provided to the well owner.
repair under=2/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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �OJ (%) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiffereni(example-3@200'and 2L100')
10.Static water level below top of casing:40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR).
I/water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/18 (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
13a.Yield(gpm) Method of test:
Air Lift Permit 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