GW1--05492_Well Construction - GW1_20240912

/ I
i
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: I.
1
1.Well Contractor Information: ,
Joseph Bailey • 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3271-A is (� qq
ft. 4% ff. ,, i)/ p/
li
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LiNER(if ap licable)
B & K Well DrillingInc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 4i1 it. 61/4 ' in, SDR-21 PVC
Company Name 16.1NNER CASING OR TUBING(geothermal closed-loop)
•
2.Well Construction Permit# We' a���`r ���®�I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.f%IC,County.State.Variance.etc.)
ft. ft. in.
fL ft. in.
3.Well Use(check well use):
Supply Well: 17.SCREEN
Water Su
p FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL •
❑Agricultural .❑Munic' ublic fL fL in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) rL ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) •
18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Bentonite Pour /ig s0°
OMonitoring ❑Recovery ft. ft. „'" y.11
injection Well: rL tt. �`��.' iV ;"-J
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) cS�i� t
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. t:MP nCBME?7,r1`1FMCID
❑Aquifer Test ❑Stormwater Drainage ft. ft. li.k.t'a-<,!t.c_ ;-3.„:„..... ;
❑Experimental Technology ❑Subsidence Control ft. ft. GIN""4` Ultif
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additionai sheets if necessary)
FROM TO DESCRI TION(color,hardness,sail/rock type.grain size,ere.)
❑Geothermal(Heating/Cooling Return)) ❑Other(explain under#21 Remarks) V fL /U fL ,�{ �,//
4.Date Well(s)Completed: /i, a�Well ID# '0 fL ^ ./fL i3��n s 01
Sa.Well Location:
asf' f�4rf- ye/44, 3owe say
NiRe A brier A ofejfg. Aloe i H) - 4.Sf` So fL ire, jay 3 id
Facility/OwncrNa c Facility TD#(if applicable) J o f4 A5ft /?QGk
6 ay/ i�ol1/GuolI ter &6navcJi. dgigd ti5'it 5®rL ors:r i i k
Physical Address,City,and Zip / ft. ft.
3 67 0 21.REMARKS /l
Countyoy 741.�1Aq C oe Parcel Identification No.(PIN) Ida .f � �j �/ ��00
viy,T 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lity
4
(if well field,one tat/long is sufficient) 22.Ce 'fication:
N W :. / 711 - / Of
6.Is(are)the welds): anent or ❑Temporary
Sign ure of a rtified Con t` D
✓ 8 .signing this form.1 hereby cert that the trell(s)was(were)constructed in accordance a with
7.Is this a repair to an existing well: ❑Yes or l 5.4 NC4C 02C.0100 or 15.4 NCAC 02C.0200 Well 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 under.21 remarks section or on the back of this form. 23.Site diagram or additional;well details:
8.For GeoprobelDPT 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: 1 24,SUBMITTAL INSTRUCTIONS
�9.Total well depth below land surface: CO (ft.) Submit this GW-1 within 30 days of well completion per the following:
For nutltiple wells list all depths if different(example-3@200•and 2L 100') l'
• 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,16171 MSC,Raleigh,NC 27699-1617
1f water level is above casing.use"+••
11.Borehole diameter:6 118 (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
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
I.
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin„over 100,000 GPD:Copy to DWR,CCPCUA
) ��/Qyr? Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) lT/ ��/ Method of test:
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resdurces Revised 6-6-2018