GW1--04274_Well Construction - GW1_20240719

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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 I fL JW ft. - i Tr✓r� o%+i`
fL ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi used Welk OR i:IiNER da le
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
V ft. t ft. 61/4 'n SDR-21 PVC
-n 1 16.INNER CASING OR TUBING clos
2.Well Construction Permit#: � Uu(y '7rC�/7 7 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,Coumly,Staten ruck.) f[. fL in.
3.Well Use(check well use): fL fL in.
Water Supply Well: 17.SCREEN -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici blic tt ft. in.
❑Geothermal(Heating/Cooling Supply) stdential Water Supply(single) fL ft in,
01ndustrial/Commercial ❑Residential Water Supply(shared) Ii GROUT
❑ini ation ❑Wells>100,000 GPD FROM TO MATERAMOUNTIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 rL Bentonite Pour
❑Monitoring ❑Recovery fL fL
injection Well:
f4 fL
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK a bk
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control fL fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheetaif
r,
❑Gcotlrcnnal(Hcatin Coolin Return) ❑Other(explain under#21 Remarks) FROM fL TO —ft. DESCRIPTION(colo hardness,soiVrock type,gmin size,etc.)
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4.Date Well(s)Completed: Well iD# xL L '� fc `r;,, G,
Sa.Well Location:
3d
irt. � 'r
E / I`eer �c s fL
Facili /Owner amc Facility in#(ifapplicable) ft. U fL r f
i !� �fL
6 t� :L
Physical A ss. ity,and Zip fL
I +
Z 5 21.REMARKS
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County Parcel identification No.(PiN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one tat/long is sufficient) 22.Certification: JUL L
N
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6.Is(are)the well(s): ermanent or ❑Temporary Si tore o e ifled we I ntractor L 9 Dat
Vie-
B signing this form.I heie r certify that the uell(s)>.ns(were)ronstnrcted in accordance with
7.Is this a repair to an existing well: ❑Yes or Vi 1 A NCAC 02C.0100 o ISA.NCAC OZC.0200 Well Construction Srandards and that a copy
If this is a repair,fill out known well construction information and explain the nature ojthe a,rthi.s 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-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: �U� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths rjdi/ferent(example-3(a)200'and-(�100')
10.Static water level below top of casing:40 (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
1juater level is above casing,use"+" ) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/18 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control JUC)
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
13s.Yield(gpm) f� / Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 6-6-2018