GW1--04285_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 AVf` 101
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for mtilti aced wells OR LINER tf a licabk
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
Alte ® ft. • ft 61/4 in. SDR-21 PVC
) � 16.INNER 4S G OR TUBING
2.Well Construction Permit#: / O�-;JOA-/T20JR/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructionpermirs ti.e.U1C.Counn•.State. Variance,etc.j ft. ft. in.
3.Well Use(check well use): ft fL in.
Water Supply Well- 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AM UNT
Non-Water Supply Well: 0 rL 20 fL Bentonite Pour J
❑Monitoring ❑Recovery ft fL
injection Well:
❑Aquifer Recharge ❑Groundwater Rctncdiation ft fL
19.SAMWGRAVEL PACK b1e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRII LING LOG attach additional sheets if
etc.)
FROM TO DESCR Or(color, rdness,soiltrock e, rain size,
❑Geothcnnal(Hearin Cooling Retu��m)��j�� ❑Other(explain under#21 Remarks) O ft fL
4.Date Well(s)Completed:"I/i{7 Well iD# fL a fc inra-m Cam/
7� 1,4
ft /Qt� 7 O /
Sa.Well Location: ft
L• l
��ar?n Cft. fL 2677
son-
Facility/Owner Namc Facility (ifapplicable) v t ft
t i
1_t_SV Ti- lk r l�ahL�/., t c,�,�.a�cs� ft ft . •.�. . •1...�.
Physical Address,City,and Zip ft fL
J
Laf, Ca 3b?yo�b Sf 21.REMARKS
County Parcel identification No.(PiN)
1013.T;.t,{t\ 1-r ram, t 1
Yd
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one fat/long is sufficient) 22.Certifica' n• A
NW A A
/
6.1s(are)the well(s): anent or ❑Temporair Kin'
re ofC " cl ontracto Da
,�,,/ ing this form.l hereby c•ert�th the n-ell(s)was(were)constructed in accordance irtth
7.is this a repair to an existing well: ❑Yes or t71RD SACAC 07C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair,fill out knomi well construction information and explain the nature ofthe of rhiv record has been provided to the xrll owner.
repair under 41 remarks section or on the back of rh£r 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-I 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: d (ft.)
For nhulliple wells list all depths ifd(fferent!example-3@200'and 2@/001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 (ft) 24a. For All Wells: Original form to Divisjpn of Water Resources (DWR).
If eater level is above casing,use-- Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/1 8 (in.) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(iUC)
Program, 1636 MSC,Raleigh.INC 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
�pm) ��'/ Air Lift Permit Program,161 1 MSC,Raleigh,NC 27699-1 6 1 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 6-6-201 R