GW1--06607_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD(GW-1) . For lntemal Use Only:
1.Well Contractor Information:
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Joseph Bailey .• 14.WATER ZONES i I
FROM TO DESCRIPTION .r ..
Well Contractor Name ft. ft
Mk' 1 B.� S4 ,t/I JTJ ,2a4e
3271-A 3?4 ft 379 ft. 5,144 bwroJccAfrie .
NC Well Contractor Certification Number 15.OUTER CASING(for multi=cased wells)OR LINER(if ap livable). .
B & K Well Drilling Inc FROM TO DIAMETER' THICKNESS MATERIAL
• 0 ft• act ft• 6 1/4 1 in. SDR-21 , PVC
Company Name `,ry/ s/_ 16.INNER CASING OR-TUBING:(geothermal closed-loop) '
2,Well Construction Permit#: aid 0►`1_ 5 765 FROM TO DIAMETER THICKNESS MATERIAL
, in.
List all applicable well construction permits(i.e.U/C.County,Slate.Variance,etc.) • ft ft.
ft ft in.
3.Well Use(check well use):
17..SCREEN
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) •18.GROUT .
❑irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentoriite Pour /O0 L'js 0
❑Monitoring DRecovery • ft. ft.
Injection Well: ft. ft. ;-„
❑Aquifer Recharge ❑Groundwater Rcmcdiation
19.SAND/GRAVEL PACK(if applicable). 4i •..,,..:.t, i,"f a .).:�•..: ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATF.RIAl: F.MPLACF.ME\TTMETHOD,E.../
❑Aquifer Test ❑Stormwater Drainage ft ft ' 1 NOV 1 i 2 pq�
❑Experimental Technology OSubsidence Control ft. ft JL
❑Geothermal(Closed Loop) OTracer ram`' "^31 11.�'
20.DRILLING LOG.(attach additional sheets i•F.necessaiF)�') :4'.
"21 Remarks) FROM TO DESCRIPTION(color.hardness.svjUiocktMse.grain size,eteJ•'-
❑Gcotlicrmal(Hcating/Cooling Return) //❑Other(explain under* 1 ft• ft �e(�S6/f l
4.Date Well(s)Completed: g/1 f,f ll'i Well ID# I�/ ® / 0 ft. 3S ft 3�/,n s444,/fe/
3 ft. eo it ei�D(✓ 3/•/v-/i icy/
Sa.Well Location: �J'�' u•I ,/
1r A /a n bogie l 4 Cl-}`r 6.0 ft /,/`v ft 'Jro6// p�#''foA
. Facil�OwnerName Facility iD#(if applicable) /!(dft.
% $ ft L11e 6-ft
f/l /3r r L4� defy lie At o�//4 /!Pt °tOP'. PG•I%17 RoC/c
d ft. ft l�
Physical Ad ress/, and Zip e/ /� !� `,
(. II L'p, r 1Z.4 4®3-6,,5 vAy 2r1.REMARKS L ' if Cou� Parcel identification No.(PiN) L ? 35i 0e 9�4 dew/Yd e a C4sy
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22,Certific tion:
N _ W
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6.Is(are)the well(s): ermanent or ❑Temporary Sit
cure o Ce fled ell ontractor l Date
B signing this.form.I hereby certifr to the uell(c)was(were)constructed in accordance with
15.4 NC4C 02C.0100 or 15A NCAC C.020r1 Well Constriction Standards and that a copy
7.Is this a repair to an existing well: ❑Yes or or
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.21 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
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: t 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: li Of (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3®200•and 2@100)
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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••+•'
6 1/18 24b.For Injection Wells:Copy to iDWR,Underground Injection Control(IUC)
11.Borehole diameter: (in•) Program.1636 MSC.Raleigh.NC 27699-1636
ry f '
12.Well construction method:Air Rota 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
g Air Lift Permit Program,1611 MSC.Raleigh,NC 27699-1611
13a.Yield(gpm) f 04 Method of test:
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-201 R
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