GW1--05586_Well Construction - GW1_20240913

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joseph Bailey 14.rWATERZON•ES .
FROM TO DESCRIPTION
Well Contractor Name
U ft In ft SM4d cif s DV�0C
3271-A ee
le it: f� (r (rive%tP�24r
NC Well Contractor Certification Number 15.0 CASiNG(for mold 'wells)OR LINER(if ap )
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
® ft U= ft. 61/4' .f in• SDR-21 PVC'
Company Name •
16.INNER C ING OR TUBING.'((ifothetmaf closed-loop}.
2.Well Construction Permit#: jf/- 65 FROM TO DIAMETER THICKNESS MATERIAL
��] ft ft in.List all applicable well construction peithi i.e.U1C,Courant State.Y'al'iadce.etc.)
ft. ft. ' in.
3.Well Use(check well use): .
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
' El Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) Vsicierrtial Water Supply(single) ft ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ,
0 Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&/AMOUNT
Non-Water Supply Well: 0 it 20 ft Bentonite Pour 2,S 6f1YN
OMonitoring DRecovery ft. ft. �0
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 ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft. I
❑Geothermal(Closed Loop) ❑Tracer .20:DRILLING LOG(attach additional sheets if necessary) - • . .• . 1-
FROM TO DESCRTION(color.hardness.soilirock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Otter(explain under#21 Remarks) ft r ft Rea Sd!/I
4.Date Well(s)Completed: VP/ay Well ID# 1 7,/ft a ft zed an /�s Or
it
3sft Sc-ft t1Ieiv eccw# S�
Sa.Well Location: 7
ftGlcsca l6pcx. le-eT I l‘prois .4(ft. ('ft rmit is4i/� 8 0✓4 5�'1
Facility/Owner Name Facility ID0(if-applicable) t II t 5-ft �1J H44 r Gee',i??'k.
I /Ti6 FCtil ljej �er6�iV ill eA4'p ii11,� jr5 ft 5, (it. G14il' 2 Reck
1�t yI/�
Physical Address.City.and Zip / ft. ft i;
D,6 21.REMARKS'
ounty h CO. De�fl e Jell rc(7 ,�� Lit (fro ,
County Parcel identification No.(PIN) ��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J a hors/.. ';/
(if well field,one IaUlong is sufficient) 22.Certification: ,�Z; .�,P •yi...L.1
i
N W 1� "-Con
CEP l Z024
6.Is(are)the well(s): rmanent or ❑Temporary
Si azure of enified Well Con for Oat
• v.signing this Arm.1 herelt e a:legr ltlslhaairti .:e 'crirr'seu6l 'n accordance with
7.is this a repair to an existing well: ❑Yes or Vokr 15.4 NC.4C 02C.0100 or 15A CAC 02C.n2nMly fT-r a ton 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 well owner.
repair under o21 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: J ✓ (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@a 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.1617 MSC,Raleigh.NC 27699-1617
If water level is above casing.use"+" I I
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
I;
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 0P11°) Method of test:
Air Lift Permit Program.1611 MSC,Raleigh,NC 27699-1611
Chlor, Tabs 11 1/2 Lbs
13b.Disinfection type: Amount:
JForm OW-I North Carolina Department of Environmental Quality-Division of Water Res'urces Revised 6-6-2018