GW1--06597_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
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1.Well Contractor Information: 1 I
Joseph Bailey .. 14.WATERzor-Es . 1I I i .
Well Contractor Name FROM TO DESCRIPTION
3271-A 10 ft 9.5 fL bile> �e�U G
ft. ft. l I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased;wells)OR LiNER(if ap licable)'
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
® ft. , ft. 6 1/4 I in. SDR-21 PVC
Company Name • � .16.INNER:CASING ORTUBING(geothermal closed-loop) .•
2.Well Construction Permit#: /®�IJi CIS'.2 .
O�� Q B FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction p rmits(i.e.U/C.County,State.Variance.etc.) ft. ft. ' in.
3.Well Use(check well use): ft ft I; in.
Water Supply Well: 17.SCREEN
PPY FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.I
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.i
❑IndustrialiCommercial ❑Residential Water Supply(shared) •
18.GROUT
0 Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Pour /y 8,if f/p
:Monitoring ❑Recovery ft. fL
Injection Well: ft ft. j
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK(if applicable)-.
:Aquifer Storage and Recovery OSalinity Barrier FROM TO UTATF.RIAI. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft. l
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) ' ..: '.:..
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) 6 ft. /�y ft
��Sei S
4.Date Well(s)Completed: qh 0/19 Well ID# 1,67 J,, (�r 0 ft 1 c it ;1'1 haf t L)*Jy' Or/
5a.Well Location: 3fft Lis ft. 6,-el �i 54,4 c`�/
mike J i r i14o4 CI- AT` Lj ft 1S ft- k� :441eiAd J�
Facility/Owner Name Facility ID#(if'applicable) 7� ft. / 45 ft. � e Rock T^y,'T�
//f &3�'d�e V i� (atle; Sherri lls Fr4�b ft ft. ..�.I-�.,< .,.' s` ;.-,-- �n
1._ i ;a
Physical
�Address,City,and
/Zip
pro ® `� e:�,(�i6 NOV
�[i/Qi/��`0 Cal Y4/t 0I�92.)2 21.REMARKS NO 1+ 1 2 Z024
•
County Parcel identification No.(PiN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L'z,+,1: C.,
(if well field,one lat/long is sufficient) 22.Certifie 'on: 41
6.Is(are)the well(s): ermanent or ❑Temporary Sian re of C ified Well Contracto j Da
B igning this form.I hereby certi, thatl the well(S)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or 1 .4 NC.4C 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 the nature of the of this record has been provided to the well owner.
. repair under i21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same i
_ 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: I
/®� I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �/y (ft.) Submit this GW-1 within 30 days,.of well completion per the following:
For nudtiple wells list all depths if different(example-3@200'and 2(0100')
10.Static water level below top of casing:40 (ft-) 24a. For All Wells: Original fo to Division of Water Resources (DWR).
• information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
Ij,yare,•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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinglover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 30 f Method of test:
Air Lift Permit Program.1611 MSC,Raleigh.NC 27699-1611
136.Disinfection type: Chior. Tabs Amount: 1 1/2 Lbs
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resource. Revised 6-6-2018