GW1--06599_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey ,4.WATERZONES
Well Contractor Name •
FROM TO DESCRIPTION
3271-A • AV ft.ft fyaft- ISadsy/frs'efi�2o7c
•
NC Well Contractor Certification Number �ps't. '977 ft. ` ���'��
15./OU✓7 ER CASINGJ (tor multi-cased wells)OR,LINER(if ap Roble)
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
• Company Name FROM0 ft _iir ft• 6.1/4 in. SDR-21 PVC
• el/. iv-��/ / `Sb 16.iNNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �/(�1�/y� FRO 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. In. I
Water Supply Well: • . 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural OMunicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) [ ential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells%100.000 GPD FROM TO I MATERIAL EMPLACEMENT METHOD&,�AMOUNT
Non-Water Supply Well: 0 ft 20 it Bentonite Pour /a AJ4y.Ssll/
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Rctncdiation
❑A uifer and Recovery OSalinityBarrier 19.SAND/GRAVEL PACK(If applicable)
q StoragetyFROM TO MATF.RIAI. F.MPiACF.ME\T METHOD
❑Aquifer Test OStormwater Drainage ft. ft. ';
❑Experimental Technology ❑Subsidence Control ft. ft. I
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) •
FROM TO I'DESCRIPTI N(color.hardness.soil/rack type.grain size.eta)
❑Geothermal(Heating/Cooling Return) ❑Od)cr(explain under 421 Remarks) U J_ ft ft f s �r•�
n i
4.Date Well(s)Completed: >�d/Sips g Well ID# �ft- R�° I r'de a/f /
5a.Well Location: art- y5 ft Yelk w 41a 44/ ,L]��� sal
n 1I<ft ft //fey
/r d Mb,Tit �k
liry/Owner Name Faeil b(if applicable) ''!!�t 4 O tlS�j f ' !/•'�-
ck•
' 25�� 10n►4✓4 Ui P/-G/®� ,vG pZ90/ ft Yf� ft •O
Physical Address.
,City,and
ip /r t ft. ft. I;: i-1,..n,.k,..,'A. ; './ ,...,+�i
• Cs74wbc CoC . (3 23l'i/7. f 221.REMARKS NOV 1 2024 •
County Parcel Identification No.(PiN)
Sb.Latitude and longitude in degrees/minutes/seconds.or decimal degrees: _ _r,
(if well field,one lat/long is sufficient) 22.Certi ation: [)':v't ii�
•
N W 0
t.
6.is(are)the well(s): ermanent or ❑Temporary n tare Cem _ Well Con' for Date
��� •
t•sign g this Arm.I here • rt that rite well(s)was(were)consmrcred in accordance with
7.Is this a repair to an existing well: ❑Yes or 'ir'g 15.4 NC4C 02C.0100 or 1 A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair-,fill out Amami well construction information and explain rite nature oj'the of this record has been provided to the well owner.
repair under=21 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: 1/66'
(ft.) ..
For nrtrltiple wells list all depths ifd eremt(example-3ts)200'and 2(m100') Submit this GW-1 within 30 days of well completion per the following:
I
40 24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: (ft)
If water level is above casing,use"+'If Processing Unit.1617 MSC,Raleigh,NC 27699-1617
6 1/18 24b.For Injection Wells:Copy to DWR.Underground Injection Control(MC)11.Borehole diameter: (in.)
Program.1636 MSC.Raleigh.NC 27699-1636
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12.Well construction method:Air Rotary 24c.For Water Supply and IOpen-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: I 24d.For Water Wells prIoducing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Air Lift Permit Program.1611 MSC.;Raleigh.NC 27699-1 61 1
13b.Disinfection type: Cihl r. Tabs ' Amount: 1 1/2 Lbs
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Form GW-1 North Carolina Department of Environmental Quality-Division of Watcri Resources Revised 6-6-2018