GW1--05503_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Well Contractor Information: 1
Joseph Bailey r
14.WATERZONES I I.
FROM TO DESCRIPTION
Well Contractor Name
3271-A I loft. /o ft- cm I Jr.8-6 -c Z a�roe
NC Well Contractor Certification Number " /.5 3 A 7 ft ayJl i I fin,-,.-tiG re 2o-i
15.$OUTER CASING(for multi-cased;w,ells`)ORA LINER(trap &able)
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
r>. ft. Jrlit. 61/4 in. SDR-21 PVC
Company Name .16.INNER CASING OR TUBING(geothermal closed-loop) '
`i 2.Well Construction Permit#:69. ^ 03,5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.file.County.State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. fc to
Water Supply I 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) stdential Water Supply(single) ft- rt. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
ID Irrigation ❑Wells>100.000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 20 ft- Bentonite Pour /y&tic HA
OMonitoring ❑Recovery ft, ft.
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG(attach additional sheets if necessary) ..' : '
FROM TO DESCRIPTI N(color,ha ness.soil/reek type,grain size,etc.)
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under##22I Remarks) f� S fft. Res,O r//
4.Date Well(s)Completed: 0��/03 N/ Well ID# //#3/ C ft' a° ft Ara1,4-# O/�il
5a.Well Location: �/ i1J�I Het a® ft. a f ft. Ye, toy", 5 dk
51;f Ant S i At0t1 si55 &NOV e!+4 fit. G 0 f`, 4j d j cj /?C C k
rU / P a^ Reek
Faacilliity// ncr Naft me ` �(f Facility iD#(i applicable) )(� 40 ft, _I of 1-'i�4o e Ree/�
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Physical Ad ress, ity,'d Zip ��✓�/ /� ft ft L.i.{y +`I/yw
. redeII C Os Liao- -Is61 21.REMARKS SEP•
1 L ZUC4
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: If:a;TA:`.f ?rC.rsrvf.-•e t�T
(if well field,one lat/Iong is sufficient) 22.Certifi •lion: D-W,"r'a+J'Gt
N W �, , 1 a 4/
6.is(are)the well(s): ermanent or OTemporary Sig :lure of rtifie Vt ontractor Date
_ 8)signing this form.1herehr certi, t at tre well(.$)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or &No 114 NC.4C 02C.0100 or 15.4 NCA 02C.0200 ll'ell Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature oft/re 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 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: u 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l"� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(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,I6ji 7 MSC,Raleigh,NC 27699-1617
if stater level is above casing,use"+" '
11.Borehole diameter 6 1/18 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) q 0°1 Method of test:Air Lift Permit Program,1611 MSC,Raleigh,NC 27699-1611
`V
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs ! '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201R