GW1--05584_Well Construction - GW1_20240913

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Joseph Bailey
14.AVA;TER,ZONES ... 1::1, .: .._....: .-..._ r-:.:,' ::::
Well Contractor Name FROM TO DE.SCR ON
3271-A a`� ` c,� 4 1/-r4ilute.�ne�
NC Well Contractor Certification Number
]kitISARITERCASINGfiiiiiiitilli4ified,:iiielli)OWLENEFE(ifa- hiiiiii : i6F,1
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 9 ft 6 1/4 1°• SDR-21 PVC
Company Name /�
6:1NNERiCASINGORTEBING.eothermal li eddoo 71
2.Well Construction Perm C�;�1` `/V it#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft fL in.
3.Well Use(check well use): fL ft. in.
17s'SCREEN `. ...
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
OGeothermal(Heating/Cooling Supply) posttTential Water Supply(single) ft fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :18 GR0[Tf >s
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METH &AMOUNT
Non-Water Supply Well: 0 fL 20 ft Bentonite Pour a fJJ
9 ( J1P
❑Monitoring ❑Recovery ft ft.
Injection Well: _
ft. ft
❑Aquifer Rcchargc ❑Groundwater Rcmcdiation •
19°SAND/GRAVEL PACK:(ifapp&Tcable)
0 Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _ •
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft
OGeothermal(Closed Loop) ❑Tracer K
ZO:-DRII.LINGtOfifattach"addihonal`sheMsifiiar9),.. -<a _•
❑Gotltcrmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCR N(color,hardness,soil/rock type,grain size,etc.)
/- 0 fL fL / s e*f
4.Date Well(s)Completed: yi/gy Well iD#4 or63 ft /.ft / r,di../ sod
5a.Well Location: fL ft y 1 ,
S 1i0 62, . lIeSe,,.. i S°i /
�'��t��'9 1i� j4I< 3 C 6 /* ft /IfL e /�aacilityin0(ifapplicable) c(o ft /`v,c fL .e •
ry aW�
Ie(�7-(� j,�' A: _rrIs4Uri ,,✓11v?7� 1/1) /1 On. V &SicG-rli_ r c dL'
Physical Add�ty�nd Zip I. / ft ft. t./
County Parcel identificat No.(FIN) (.1C i/1 IF rs TeJ vI e
q �f /
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ?f/ayW�.3l)/14'1/4�
(if wcll field,one Iatllong is sufficient) 2 .Cer' tion: I A
`N W ` IP", R-.. ev, ...-. /r a
if
6.Is(are)the well(s): ermanent or ❑Temporary Sign tare of enified ontract "V`t F A=�.#j al.
r. �..Y �0.�in)
/' By igning this form.I hereby cert� at the twill's)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �AItT I A NCAC 02C.0100 or 15A NCA 02C.0100 py,tt;ryv on tV L`F p 1pgrds and that a copy
If this is a repair,fill out known well construction information and explain the nature of the o this record has been provided to the well owne ' 1
repair under d21 remarks section or on the back of this form.
23.Site diagram or additional wel>1ft(is;,;t t 7,rrr ;,e,ij
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page ito:provide0 diti one ll construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach a ditional pages if necessary.
drilled: at. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
(ft.) Submit this GW-I within 30 days of well completionper the following:
For nndtiple wells list all depths if different(example-3Qa 20 • ad 2(a3100') Y P
40 24a. For All Wells: Original forth to Division of Water Resources DWR.
10.Static water level below top of casing: ft. (DWR)
If water level is above casing,use"+ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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
Air Rota 1, 1
ry 12.Well construction method: 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
13a.Yield(„wpm) !
1 a pm Method of test:Air Lift Permit Program,1611 MSC,Raleigh',NC 27699-1611
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018