GW1--04272_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 p fL IRA ft I.v ` rU'r Zaoo
ft. ft.
NC Well Contractor Certification Number 15.OUTERC*1NG"formatti-casedwelts ORI7i�R ds licabte
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
ly rt. ft- 61/4 in. SDR-21 PVC
Company Name
bsw� an y-sad 7 FR INNER CASING.�S[NG ORT I DIAMETER
e
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constuction permits(i.e.UIC,Cotmty,State.Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in.
17 SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici al/Public fL R• in.
❑Geothermal(Heating/Cooling Supply) srdential Water Supply(single) ft. A. in,
❑Industrial/Corrtmercial ❑Residential Water Supply(shared) 18 GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL Bentonite Pour
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SANDlGRAYEI;PACK.if b1e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRU"NG LOG. a"tional A=ftffaecegwry�
❑Geothermal(Hcating/Cooling Rctum) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,wilt o k Mm g.i.
ft. ft
4.Date Well(s)Completed: �� �y Well ID# LOAd Sgd/
ft b ft Vwyll 0 r
r
5a.Well Location: I1 0 fL ft. k 11va/ r1Lq S 4r
G✓a�rt� JAM.'�h �+✓�r�icbw�� ft G ft. t I
Facility/OwncrName Facility lD#(ifapplicable) t7 ft. f ft
d A14l&# r'l0,0* ,ile.Nl.
Physical Address.City,and Zip u/ L,� Q�� ft It.
L co° i 1-2 22.REMARIKS . .'
ounry Parcel Identification No.(PIN) s~ �' �" t+.� l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JUL i
(ifweli field,one lat/long is sufficient) 22.Certifc ion• /
Wes/ •!`// IfY��:Tiy4.Lrir��srlt A"r•w^�It` ' r
6.Is(are)the well(s): Wermanent or ❑Temporary Signa rc of C ified well Con for a
By signing lhi.c Jorn.I hereby c fify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11114000
19A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthit is a repair.fill out known we11 construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under=21 remarks section or at 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-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: - ` (ft.)2@100') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd{Jfereni(example- g200'and
24a. For All Wells: Original form to Division of Watcr Resources (DWR),
10.Static water level below top of casing: 40 ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1(wnier/erel is above casing,use"+'
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) /s� Method of test:Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
I�
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 LUS
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised(r6-201 8