GW1--05487_Well Construction - GW1_20240912

to
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Contractor Information:
Joseph Bailey ,a.WATER ZONES I I •
Well Contractor Name FROM TO DESCRIPTION
3271-A /9 ft 14pt ��i fin-c,fritne
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING(for moltl-cased wells)OR LINER(if ap licable)
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 f• g(ft. 6 1/4 I i'• SDR-21' PVC
• Company Name • 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: We"-
19 itoxI"!�/--o5 _FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.OIC County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft i in.
Water Supply Well: 17..SCREEN
PPY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ,
❑Agricultural ❑Muni al/Public tL ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT • '
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft Bentonite Pour 33 ,4k ii/A
❑Monitoring ❑Recovery ft. ft. I
Injection Well: ft. ft. ._"' rt' 7+F ""
s�.,.0e ._ 3 fr,..,
❑Aquifer Recharge ❑Groundwater Rcmcdiatiom 19.SAND/GRAVEL PACK(if applicable)• . .- S" 't'•••'L.✓.
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO h1ATERIAI. S L iFM1IPI.A6FW}F\T METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft. I' t-I A G / 4
❑Experimental Technology' ❑Subsidence Control ft ft. 1 IF•fGf."4:GPo-I ;ssrs .z_„„l�•„
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets ff necgia`rg)'u''IZ 'iT • "'•"'"'•
FROM TO DESCRIPTION(color.hardness,soil/rock type.grain Mae.etc.)
❑Geothermal(Hcating/Cooling Return)` �/❑Other(explain under#2I Remarks) ® ft /0 ft fled. ��l d
4.Date Well(s)Completed: 0/2OA% Well iD# L or 1 1 0 ft. .1�ft / (o' 'f/ ia//
Sa.Well Location: a�t /_0 ft ( ,e/%4//"'®w
CL1-7. G 0 ft. (�1 c-ft t.veyidizil sseicivseld
Facility/Owner Name Facility lOb(if applicable) t15ft. Ca`0 it. /1. t (,� Roc
3 cRC B c rcl+e r S errrlI f ri Ale. 2 4 3 3 0 f t- d a� "red i /?Gc/
Physical Address,City,and Zip '` /�h �/y/�/�) t�T
C ! k/U Cf. 76V)0A 401 %ds- -2LREMARKSWrit
l �f ^.
County Parcel identification No.(PiN) 7 4� i i+0 LiA f q I F eer/ �j�Z�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !.✓C/ 6•ru u1 e"4'l l.r by. -ca u /,1
(if well field,one lat/long is sufficient) 22.Certif ation:
N W44,1;*1 _14O6.is(are)the well(s): En Permanent or ❑Temporar Si_ tore of nified ell Co Date
Bt riming this facto.I hereby che well(.)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo l.). NC4C 02C.0100 or 15A NCAC 02C.0200 II''ell Construction Standards and that a copy
If this is a repair.fill out known well construction information and explain the nature of the of this record has been provided to the well owner. .
repair tinder.21 remarks section or on the hack 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 1 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: (ft') Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@,200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing:40 (ft) information Processing Unit.1617 MSC,Raleigh,NC 27699-1617
If water!eyed is above casing.use"+" •
6 1/18 24b.For Injection Wells:Copy to DWR,Underground injection Control(IUC)
11.Borehole diameter: (in.)
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
13a.Yield(gpm) Method of test:
Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Chlor. Tabs Amount: 1 112 Lbs
I .
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resource- Revised 6-6-2018