GW1--06608_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey ,. 14.WATER'ZONES I I. -
FROM TO DESCRIPTION
Well Contractor Name ft. %eft l�/ ,Lire 6
3271-A 9 ft. ft. i; .
NC Well Contractor Certification Number IS.OUTER CASiNG(for multi-cased wells)OR LINER(if an licable)
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
rdi' ft. fel rt. 6 1/4 in* SDR-21 PVC
Company Name �A/ y�V//�s/,/� 16.INNER CAING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: e,g®d J Ihr !V' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 0. U1C.County.State.Variance,etc.) ft ft in.
ft ft ' in.
3.Well Use(check well use):
Water Supply 1 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Public ft. ft. in•'
•
D.Geothermal(Heating/Cooling Supply) idential Water Supply(single) rt ft. in.;
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT •
D irrigation ❑Wells%100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Bentonite Pour /46ds,"ei%jj'd
❑Monitoring ORecovery ft. ft.
Injection Well: ft. ft. I
=Aquifer Recharge ❑Groundwater Rcmcdiation 19,SAND/GRAVEL PACK(if applicable) •
(=Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test DStormwater Drainage ft ft. ;'
❑Experimental Technology ❑Subsidence Control ft ft. i
❑Geothermal(Closed Loop) OTracer 20:DRILLING.LOG,(attacli additional sheets if necessary)
FROM TO DESCRIPTION( Ior,hardness.soil/rock type,grain size.eta)
❑Geothermal(Heating/Cooling Return)� ❑Other(explain under#21 Remarks)� ft. ®6 ft ped $c '/
4.Date Well(s)Completed: / e Well ID# �4l`� /0 ft. ,..319 ft. Ale//7 fa
s 7/
5a.Well Location: Oft R. ,orlrRo SQ% 6
MItY ry j-ft d! ft s ied f.-1a/.d ad i<
Facility/Owner Name Facility i0#(if applicable) 90 ft. forit. 6 �iye etic �J i (a Sfi&i Ifa, /i� /lk 1 Ae .Of sy® ft. ft ,
Physical Ad s.City,and Zip ft ft 1' ; n is- r ";1 ?:yn n 1
ie of • �fB✓I" --0pi,-9/ j_• 21.REMARKS I,a �. N.a,: "! 11.;„„ .
�n
County °y Parcel identification No.(PiN) ' NOV 1 v 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certific 'on: '`i""''. ..._ '' `
N • W 'o. -
6.is(are)the well(,): ermanent or OTemporary
Siena re of C tfiefl Contractor Date
Br1 if going[historic.I hereby cell' �thatl the well(,)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or 11%I11"-- --- 15.4 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=21 remarks.section or on the hack of ticis form. I'
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.
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drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V• (ft.) i'
Fornt«Iliple wells list all depths if different(example-3(a;200'an 2(ar100•) Submit this GW-1 within 30 days'of well completion per the following:
24a. For All Wells: Original forth 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 1/1824b.For Injection Wells:Copy to DWR,Underground Injection Control(iUC)
11.Borehole diameter: (in.) Program.1636 MSC.Raleigh.NC 27699-1636
1'Air Rotary
12.Well construction method: 24c.For Water Supply and OpenL 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
(gp m) 25"6A d Air Lift Pennit Program,1611 MSC,Raleigh,NC 27699-i611
(l °"f Method of test: I
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
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Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018