GW1--04279_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 I DESCRIPTION
3271-A lir
ft ft. r e
13Qft �3 ft. /rle
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0
ft. 1 ft. 61/4 in SDR-21 PVC
16.INNER CASING OR TUBING eoihet•taal ctesed-loo
2.Well Construction Permit#: AIN FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perm s(i.e.UIC,County,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
cultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
an On ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL Bentonite Pouf
❑Monitoring ❑Recovery ft. ft.
injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL fr
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Re m FROM TO DESCRIPN(color,hardness,sodirock e, min size,etc.)
arks) ft. ft
Q 4'/
4.Date Well(s)Completed: Well ID# r/T ft ft /V i/n s/3'•
5a.Well Location: >S fc ft. 014"
DIGS &sJhal_ qf
ft.
Facility/OwncrName Facility lD#(ifapplicable) 4(rft. (or
'_ fL Ad C
1S0'[ Ler�?d �X��4Th. 2� fL (/
Physical Ad css,City,and Zip r ft. ft • - •^ , 7
7 C6 21.REMARKS
County Parcel identification No.(PiN) 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certifi anon: WIG:p,.;>t,�:�r: ?s-r.{Ofi.4`'uf
N W
6.is(are)the well(s): ermanent or ❑Temporary Sign re of ertified ell coV, ,h.,
r
�� B ,igning t is form.I here!,c the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LtiFo A NCAC 02C.0100 or ISA02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner
repair under:;21 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-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:�2 , (ft.)
Fa nudli le,cells list all depths; di erent p (a� i7 �� ) Submit this GW-1 within 30 days of well completion per the following:
p p f Jj (uam !e-3 20 'arsd Z v 100' Y P P 1;
10.Static water level below top of casing: 40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/1 H (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
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
13a.Yield(gpm)
l Method of test: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 6-6-2018