GW1--05476_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
fnjt^1C e 14:WATERZONES I Ill Contractor Namc FROM TO DESCRIPTION
We
qs � 9 ft, 1
z is--741a 3nft ..p35-ft. 1 .
NC Well Contractor Certification Number 15.OUTER CASING.(for multi-cased wells)OR'LINER(if ap flyable)
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft S 7 ft 611/8 tn' SDR-21 PVC
• /� 16,INNER CASING OR TUBING(geothermal doled-loop)
(J L FROM TO 2.Well Construction Permit#: � J � DIAMETER THICKNESS .MATERIAL •-
List all applicable well construction permits(i.e.UK.,County,State.Variance,etc.) 0 ft (7'7 1/ft. 1eI ik in.
.(C , 40
3.Well Use(check well use): ft rt, in v ! (/ V
Water Supply Well: 17:SCREEN • • . - . .. .. . -
QA Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
i DMunicipal/Public ft. ft. ' ,in.
Geothermal(Heating/Cooling Supply) oiltesidential Water Supply(single) ft ft in.
DIndustrial/Commercial OResidential Water Supply(shared) ._
PP Y 18:.GRODT,;�:._ ... -.
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft Do ft. /.QP"-)Oy ,8 le"
Monitoring Recovery O ft. 7/ ft- pUG+ie N c eRA,�at.IL
Injection Well:
ft fcA uifcr Recharge �GroundwatcrRcmcdiation . 19.•SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
13Aquifer Test DStormwater Drainage ft. ft. '
DExperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Op�Tracer :'�
6...P ZO.;DRiLLING LOG additional R aecnaary):r�;'�;..,.i .„P':",;:i. ._-,,
DGeothennal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness soiUr&kPtype�gryfn,s--- '4''/rs
b ' I� ,..0G;4- orr, . ryA
4.Date Well(s)Completed: 'ler r /°� Well ID# 315 ft. t.l� ft. go/- . i.0 , `1 1 2 10C4
5a.We j ocation: 'L J ft. S / ft. Ali
/i C Irrt0:11IiC:ra 7,rr..,.
Ira r k' S:4m p •er 6SfL 1r0 ft. Jc14�/e C4' L ve-Q, o(b
Facility/Owncr Name Facility ID#(if applicable) 70 ft' ft ,( ,p,i- `vGk.
3 z A'Lp t'L V
c'Aa.''•:Cron 1c fit.►Ios 7t.
' rt• N'I.J (hek7Le
Physical Address,City,and Zipt 3U0 ft. giii--e
le Gtr-itC. 44 74k 5.4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
N W , —� �—o)(—o�oZy
6.Is(are)the well(s)0Permanent or Temporary Signature of Well Contractor Date
By signing this form,I hereby certifp that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or o xit/t 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this 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 site details or well
construction,only 1 GW-j is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ! 7 SUBMITTAL INSTRUCTIONS
V
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it-different(example-3@200'and 2@I00') construction to the following:1
10.Static water level below top of casing:40
If water level is above casing,use'+,•If Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 18 (in.) I.
24b,For injection Wells: in addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.au construction to the following:
ger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 tl2 tbs completion of well construction to the.county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Res urces Revised 2-22-2016