GW1--04276_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
NC Well Contractor Certification Number
15.OUTER CASIN for muds-cased wills OR LINER if le
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
tt. ft 61/4 in- AR-21 PVC
Company Name
., � 16.INNER CASING ORTUBING. o thermal dosed-loop)
2.Well Construction Permit# 14r_' L�L% ���! J/7ti FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well consn uction permits(i.t UIC.County,State.Variance,etc.) ft- fL in.
3.Well Use(check well use): tL ft. in.
i
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ��.d=t.l
blic ft fL in.
❑Geothermal(Heating/Cooling Supply) ater Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Itri atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 fL Bentonite Pouf
OMonitoring ❑Recovery ft ft
Injection Well: ft. ft
❑Aquifer Recharge OGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL.PACK aFROM TO MATERIAL F.MPLACF.MF.NT METHOD
❑Aquifer Test ❑Stormwater Drainage rt. ft.
❑Experimental Technology ❑Subsidence Control fL ft
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG athchaddidenatsheetsK
❑Gcotltcnnal(Hcatin Cooling Return) TO DESCRIPTION(color,hardness,wfl/ ck e, Din size,etc.)) ❑Other(explain under#21 Remarks) ' ft j tft. I .,j
4,Date Well(s)Completed: Well ID# ft /ft f`wSol I
5a.Well Location: i ft ) ft
ft ft ► Wry
Facility/Owncr//Namc Facility ID#(ifapplicablc) ft ft L /wr /
Ic4Jvf ��F �l c1•z';sIjk.. AC. 5 7s��S' fit-
Physical ft
Addr ss.Ci ,and Zip r ft. ft " {
21.REMARKS ti..
County Parccl Idcnti icaf Lion No.(PIN) 2074
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees. a _
(ifwcll field,one Iat/long is sufficient) 22.Ce •fica•on• I�tt$;�r1s6Try'rZ - tt��r�����LL�
N W
i�
6.ls(are)the well(s): rmanent or ❑Temporary a ure Certi flfd Well C tractor
B signing this form.I hereb cerrify that the nrll(s)was(were)constnicied in accordance with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0,00 or A NCAC 01C.0200 Well Consnvcrion Standards and that a copy
Ifthm is a repair.fill out known well construction information and explain the nature of the of this record has been prrmided to the xrll owner.
repair under-11 remarks section or on the back of this fern
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:
/f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l9 (ft.)
For mtdliple yells list all depths ifd;/fereni(example-3C3a 100'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
l0-Static water level below top of casing 40 (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
1
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
voter level is above casing,use
11.Borehole diameter: 6 1/18 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
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
Method of test:
13a.Yield(gpm) A) (�1t/�
/ 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 6-6-201 R