GW1--05505_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey •
. . .14.;WATER ZONES i i .
Well Contractor Name FROM TO DESCRIPTION
3271-A Diet a"t_)3f` �2Cc' ft-gerafto 2eme
fL ft. i
NC Well Contractor Certification Number 15.OUTER CASING(for malfi-cased wells)OR LINER(If tip Hcable) . .-
B & K Well Drilling Inc FROM TOTO DIAMETER THICKNESS MATERIAL
f
Company Name •
9d ft' / ft' 6 1/4 in' SDR-21 PVC
/��9 a4"5/ 16.INNER CASING OR'TUB AM(geothermal'closedNoop)
2.Well Construction Permit#: �� FROM TO DIAMETER THICKNESS MATERIAL
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List all applicable well construction permits(i.e.WC,County.State.Variance.etc.) ft ft in.
3.Well Use(check well use): ft ft. in.
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Water Supply Well: 17.SCREEN
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici lc ft. it ! in•
❑Geothermal(Heating/Cooling Supply) stdential Water Supply(single) ft ft in.
❑Industrial/Cornmercial ❑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 d? e Q
ti5
❑Monitoring ❑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 EMPI.ACF.MENT 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 DESCRIP ON(color, artiness.sail/rock type,grain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain unjdcrr#21 Remarks) ft r (eft :r: J4L..„:
`• tart?t?to -2A ft. sJ ft
um
4.Date Well(s)Completed: J Al.!.. Well �� � ?S
5a.Well Location: Yv ft lo ft fiam//T444. liamfrifi„ is tirxi' V) ft 9,'ft3b g' 1
acility/ me acility D#(ifapplicable) 7rft / l0 ftft. a�as-d fete"SUolle17i.p 2r4r0/nr1f,1t avaz /IJorLJa/daml� jPhysical Address,City/and Zip / fL fL �.1+•r�..!i/ ^' -•
21.RETdARKS 1•County Parcel identification No.(PiN) ZOZ4ifi :r"�:t•Y.� art•.,.,-,.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ..:,y
(if well field,one lat/long is sufficient) a 22.Certi cation: '�41VL'a
..
N W ••
�,.- 1'
6.Is(are)the well(s): ermanent or OTemporarycure of enifie Well Cont:et./ Date
•signing this fonn.l hereby ce 'If that the well(,)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 5A NC.4C 02C.0100 or 15.4 N,IC 02C.0200 Well Construction Standards and that a copy
If this is a repair.fill out known well construction information and explain the stature of the of this record has been provided to the well owner.
repair under c21 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:
1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: iT. (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3"200';Ind 2@l00')
40 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: (ft.)
!(tracer level is above casing.use"I' information Processing Unit,11617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/18 (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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
/OG,0�'! Air Lift Permit Program.1611 MSC•Raleigh,NC27699-1611
13a.Yield(gpm) Method of test: '
13b.Disinfection type:Chior. Tabs Amount: 1 1/2 Lbs ,
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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