GW1--05507_Well Construction - GW1_20240912

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14 WATER ZONES i i '.
FROM TO DESCRIPTION
Well Contractor Name qy ft. 00 ft. �ed �j4G�� e
3271-A s 1[/� / - .
NC Well Contractor Certification Number /570" /. " miff G?l fc
15.OUTERCA ING(for multi-cased OR LINER(if ap ficable)'
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
11, ft. ft• 6 1/4 ' 'in- SDR-21 PVC
Company Name .
• l�//- / 3^ a ��fa 16.INNER.CAS) G OR TUBING(Reothermat closed-loop) '
2.Well Construction Permit#: F�p w As ( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.State.Variance,etc.) ft. f0 l in.
3.Well Use(check well use): tr. ft in.
Water Supply Well: • 17:SCREEN PP Y FROM TO DIAMETER SLOT SIZE THICKNESS' MATERIAL
❑Agricultural ❑Munic al/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. in.
❑lndustrial/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 Bentohite Pour A 41)10
❑Monitoring ❑Recovery ft. ft.
injection Well:
ft. ft. •
❑Aquifer Recharge • ❑Groundwater Rcmcdiation ?.,'
-19.SAND/GRAVEL PACK(lf applicable} 1)..1,- _ "a p:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATF.RIAI. EMPI.ACFMFI~'T'htI TROD ft. ft. Al 3�..4, I'�LI
❑Aquifer Test ❑StotmwaterDrainageSFp 1 .
ClExperimental Technology ❑Subsidence Control ft. ft. G raZ4
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets.lfsseced3ary)�A:t:`c.-, zi ....
FROM TO DESCRIP ON(color.hardness.soil/rock ci e.gratiarz rite.),
❑Geothermal(Heating/Cooling Return)q ❑Other(explain/under#21/Remarks) ft /� ft n� S6i�/ ,/ V'`.'u 'sG ' o
4.Date Well(s)Completed: if/11/q if Well ID# Z or-,4 i 0 ft. jc ft. ,?td Q rgr7 a 5o
5a.Well Location: yr ft. io'ft. /3 ,? cif/ /� '
NMI $h� 0844 11 13 iyr1l? will'ci0// 400. $3 fL /J/SJ ft. /�+o�,e�/J ill✓//56l i/
FacilliitPit�wncr Name
�f�' A Facility i M(if applicable) /5"fu [Y�a it
V � ` Fr aee
k.
'?5/f A/erTyl 4ve. &ivei WC. a'6o3, P ft 2Q _` 6i-`r.ci Roc /<
Physical Address,City,and Zip Jeff
Lincoln CO. 0649.X 21.REMARKS
County Pa eel identification No.(PiN) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certif anon• l
;.NW /111‘.
6.Is(are)the well(s): ermanent or ❑Temporary S azure o e far ell o Ira or. Date
p.cigning this form.I hereby c in,that the well(s)was(were)constructed in accordance with
7,is this a repair to an existing well: ❑Yes or ISA NC4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain rue nature of the of this record has been provided to the well owner.
repair under c21 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 I 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: (241( (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'and 2@.100')
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing:40 (fL) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
II-water level 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
�,./) Air Lift Permit Program,1611 MSC,Raleigh.NC 27699-1611
13a.Yield(gpm) V`/�•► Method of test: 1 .
13b.Disinfection type: Chloe. Tabs Amount: 1/2 LbS
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018