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Home My WebLink AboutGW1--06598_Well Construction - GW1_20241112 I. . I WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: 1.Well Contractor Information: I I Joseph Bailey 14.WATERZONES FROM TO DESCRIPTION Well Contractor Name • �'1 n ft. ) 4 afL Sil ,(�!f�� f'0�C 3271-A 3 21 !�J 4 ft t' ,41/ imp?are..2o4c NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) B & K Well DrillingInc FROM TO DIAMETER THICKNESS MATERIAL 0 ft sr fL 61/4 in• SDR-21 PVC • Company Name • 16,INNER CASING OR TUBING(geothermal closed-loop) Wm �C//- a1q o o/ FROM TO DIAMETER THICKNESS MATERIAL I 2.Well Construction Permit#: �/ f O� / fL fL in. List all applicable well construction permits lie.U1C. nuntr.State.Variance.e,etc.) fL ft. in. 3.Well Use(check well use): 17.SCREEN Water Supply Well: - FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL ❑Agricultural ❑Munici blic ft fL i in. - i ❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. it. , in. i ❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ❑Wells%100,000 GPD FROM TO l MATERIAL I EMPLACEMENT METHOD&AMOUNT ❑iniWaon /•S/S7jsr l�A Non-Water Supply Well: 0 fL 20 fL Behtonite Pour :l OMonitoring ID Recovery fL ft ' Injection Well: ft I ft. ❑Aquifer Recharge ❑Groundwater Remcdiation 19.SAND/GRAVEL PACK(if applicable) ❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD a ❑Stormwater Drainage ft fL i ❑Aquifer Test ❑Experimental Technology OSubsidence Control ft ft OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) FROM TO DESCRIPTION(color, ardness.soil/rock type.Frain size.No) ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft / o ft lege p y., fr/�fd'/c d fL a,�'ft r'earn'I 5.07 4.Date WeIi(s)Completed: `�/�/2r Well iD#� / 5a.Well Location: �{� ''1 sft . v fL-Ye/biz,/ L rt eel .5 01 ,r• L rA i�hii /t/��'a /� _ / O�`�/' fL v fL ',TNt 1 ,`61k til� {•t+/rR ! yI�� /bee "'If! ft. t ft i/e CA Faciliry)OwnerNamc ems' J�� ,��,, Facility IDS(if pplicablc)ry�1 G'�4 - J� I� P�vyw /ram Q( JJ ft fL r . =.''' -• J... - - ft I ft I I ••'a.: fit'1. Physical Address.City,and Zip C4T (4- 3, lfs3 b�i 21.RE4ARRS NOV i 2 2 F Z4 County Parcel Identification�o.(FIN) i�?i,;.cam :�'r" �-,Er i.�.. i 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ir;` CYz`as ,.:3 (if well field,one lat/long is sufficient) 22.Certification: ' N W // ', 1/ . fa/3 77mm i / Sig re of erti i Well C ctor r • Date 6.is(are)the well(s): ermanent or ❑Temporary , Byigning this form./hereby certify ter, to steel(s was(were)constructed in accordance with 7.is this a repair to an existing well: ❑Yes or laAt6 15.4 NCAC 02C.0100 or 13AI NCAC 0' .0200 Well Construction Standards and that a copy )f this is a repair.fill out known well construction information and explain the nature of the of this record has been provided to the sell owner. repair under=21 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 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: / l 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 3G (f ) Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if different(example-3 f.200'end 2 f 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 limiter level is above casing,use"+'• I ' 6 1/1824b.For Injection Wells:Copy to DWR.Underground Injection Control(TUC) 11.Borehole diameter: (in.) Program.1636 MSC.Raleigh.NC 27699-1636 Air Rotary iv land Open-Loop Geothermal Return Wells:Copy to the 12.Well construction method: 24c.For Water Supp_' (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(gpm) Method of test: ad Air Lift Permit Program,1611 MSC.Raleigh,NC 27699-1611 C or. Tabs 1 1/2 Lbs 13b.Disinfection type: Amount: i Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6 6 201 R