GW1--04273_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ' ft it v
3271-A
NAfft ft v�
NC Well Contractor Certification Number I5 OL TER CASING for multi cased webs OR LINER if a iicabh
B & K Well Drilling Inc FROM TO , DIAMETER THICKNESS MATERIAL
rt. ft 61/4 io• SDR-21 PVC
Company Name
Ov, Day �(/0,3 7 16 INNER C. ING OR iTJBING eothermat It IV lES
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counrv,State.Variant e.etc ft. ft. I in.
3.Well Use(check well use): SCREEN17. ft in•
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. e. is
❑Geothermal(Heating/Cooling Supply) stdential Water Supply(single) ft ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) I8.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Pour
❑Monitoring ❑Recovery ft ft
injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK(if ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F.MPLACF.MF.NT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRUArNG LOG attacbaddidotsalsheefaU necellawYT
FROM TO DESCRrP N(color,hardness,soi 1 k e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Otltcr(explain under#21 Remarks) ft ft tf I
4.Date Well(s)Completed: s -a� Well ID#/70V5( fL ft r.QMf s o' ea
5a.Well Location: sift ft / v
-t reyen ril t e ft ft 7ok;d
Facility/OwncrNamc Facility 1D#(if applicable) ft. ft J Q
l_Sg lll�i►r/d�k i�� ( /.�d�/�.. a 20/_T_
Physical Address.City.and Zip
ft. ft
1; 'lod 60. ?/ 21.REMARKS
County Parcel identificatioon No.(PIN)•AJ'I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one IaUlong is sufficient) 22.Cer" tion•
N W 1 202 a
6.ls(are)the well(s): ermanent or ❑Temporar} amre o Certi t WeII C nt ctor Da
-c t.
Brsignin thLcJorrn.lhereb rtifvlh4(p11$Iii3IdG 118o3(wefel'cM1!liitd]id ordanceu irh
7.Is this a repair to an existing well; ❑Yes or 15A NCAC 02C.0100 or! NCAC 02C.0200 We"ialltlj•'wfVtattdards and that a copy
If is a repair,fill out known well construction information an explain the nature of the of this record has been provided to the well owner
repair under a2l remarkv sectinn or on the back of thLv 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 t GW-I is needed. indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For mtdtiple trells list all depths ifdf ferent(example-3(3a 200'and 2@100�
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: �� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 1/18 24b.For Injection Wells-Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter. (in.) 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
t 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
13s.Yield(gpm) � ' 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 6-6-201 R