GW1--04253_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
fL fL � ime ove
3271-A
ft. fL
NC Well Contractor Certification Number
I&OUTER CASING for mvltl cased webs-OR;LINTE'R if a
B & K Well Drilling Inc FROS TO DIAMETER THICKNESS MATERIAL
Company Name ft. I J7'ft- 6 114 in SDR-21 PVC
7yjl/ O Q 16.INNER CASING ORTQBING c
2.Well Construction Permit#: V 7 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc) ft. fL in.
3.Well Use(check well use): ft• fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Munici !tc iL ft. in.
❑Geothermal(Heating/Cooling Supply) sidenlial Water Supply(single) ft ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUP
❑Ira atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Bentonite Pour
❑Monitoring ❑Recovery fL fL
Injection Well:
f4 ft h
❑Aquifer Recharge ❑Groundwater Rcmcdiation �-
19.SAND/GRAVEL PACK ifs ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPIAeg ENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. tt
❑Experimental Technology ❑Subsidence Control fL fL „ 1rf`/ )&A
❑Geothermal(Closed Loop) ❑Tracer 20.DRIIIING LOG attach additional
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCR N(color,hardness,soil/rock a in size,etc.)
A Q ft. fL = O
4.Date Well(s)Completed: /�7 Well ID# �Or /% fL /ft
W
Sa..�Well Location:
// f �j l ft ft. /b
�` t/�� LV /tJ•/17ti ��M� L fL
Facility/Owner Name Facility TD#(ifapplicable)
I i 1 1� , fL fL
Physical Address,Ci 11
,and Zip / ft. ft.
n��Ge7 eo 901,40)9
0,!J�D)9 21.REMARKS
County /7tY Parcel identification No.(PTN) Lr7wI
y/ olva Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: X to
(ifwcll field,one]at/long is sufficient) 22.Certify n•
N W
6.ls(are)the well(s): Vermanent or ❑Temporary I t eofC ifi Contrac r D
���� p signing then farm.I hereby cer t the ivell(s)was(were)constnucted in accordance with
7.Is this a repair to an existing well: ❑Yes or '� 0 I5A NCAC 01C.0100 or lSA N 07C.0200 Well Construction Standards and that a copy
lfthis is a repair.fill out known well construction int/brmationandexplain the nature nfrhe of this record has been provided to the xell owner.
repair under=21 remarks sectinn or on the back of rhis 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'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled. ���f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: tt.
For multiple wells Cut all depths ifdi(ferent(example-3@200'and 2L100') ( ) 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 Division of Water Resources (DWR),
l/mazer level is above casing,use`+" Information Processing Unit,1617 MSC,Raleigh,NC 2 7699-1 6 1 7
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
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Lift Penn Program,161 i MSC,Raleigh,NC 27699-16 1 1
13b-Disinfectlon type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 6-6-201 R