GW1--05495_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: •
Joseph Bailey .. 14..WATERZONES .•. - •
FROM TO DESCRIPTION
Well Contractor Namc
3271-A /G4t /t.f ft Sni4// rEertif e e
ft. ft I
NC Well Contractor Certification Number 15.OUTER CASING(formolti-cased wells)OR LINER(if an licable) -
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. / ft 6 1/4 1, ;in• SDR-21 PVC
Company Name •
• .16.INNER:CASIN'G OR•TUBING(geothermal closed loop) - .
2.Well Construction Permit#: ig Q Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County.State.Variance.etc.) ft. ft in.
3.Well Use(check well use): ft ft. in.
l Well: 17:.SCREEN
Water Supply Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mums• I/Public ft. ft. In. .
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑IndustriaUCommercial OResidential Water Supply(shared) 18.GROUT
0 Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 it Bentonite Pour iA ,(�Q,s HP
❑Monitoring ❑Recovery ft. ft '' .*,
,,, y.
injection Well: •ft ft. . "4-r.,0 I;':. i._i
DAquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK(if applicable) C'i 0 • s
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL V L 1 FtuntiC1$IJ. 'J'lntETHon
l
❑Aquifer Test ❑Stormwater Drainage ft. ft. I f,.: ..,;-
❑Experimental Technology ❑Subsidence Control ft. n - DAirlelss-.r•
mGeot\letma\ C\osea Loop) OTcacec 20.ORiLGING:LOG(attach addition l sheetsiinecessar4l 1
FRONt TO DESCRIPTIONtcolortiatdnesssollrtoclt t}4e.¶, ,lm,etc..*;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft !I (ft. Redsd,��
4.Date Well(s)Completed:f/ao/sal Well iD# r(�/ft• ft /?( /� ��� /
Sa.Well Locati n: 3 ) f., c f. 1?d kci1 ¢3I7'+ii/ 54/ily fe/'
inil4� Tler coe 75TL /Ocft i? Sg4d'y du & tic
y � i J�
Facility/Owner Na / Facility UM(if applicable) / of. $5 /fl f&"-Aid 6 V/L 0+
G'i3' C.Parkdye, �is7 i, i i x agog/ 12 1 /k7 ft4 G 001 m J f{ ) flock(
Physical Address,City,and Zip /y 5ft IN cit. 6-rot fro / a k
Cii R 7 a 2f.REMAARKSQ /�
my !/Q Parcel identification No.(PiN) `/ ife4 i e'hde`^ r-2 24'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat./long is sufficient) 22.Certifi ation: i
I
N W
. --444-4
6.ls(are)the well(s): m eranent or ❑Temporary Sign are of C ified I Con tc'r Dat
Si'.gning this form.1 hereby cer fp that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: DYes or 11110itr- 15.4 NG4C 02C.0100 or 15A NCAC'(12C.020(1 If 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 smell owner.
repair under.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: IOC.' (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(=ample-3@200'and 2@l00')
40 24a. For All Wells: Original'form to Division of Water Resources (DWR).
10.Static water level below top of casing: (fL) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing.use"+" '
11.Borehole diameter:6 1/18 (in.) 24b.For injection Wells:Copy to DWR.Underground Injection Control(NC)
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
• ?/ Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) `J 6/ Method of test:
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resouicos Revised 6-6 2018
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