GW1--06725_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
Joseph Bailey 14.WATERZONES
Well Contractor Name ft FROM TO I DESCRIPTION
3271-A 120 ft. 1 ff ft 4j'`/ c•^'L�v' `7 e..
1. ,
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
0 ft. y l ft. 6 1/4 , in. SDR-21 PVC
Company Name • ' , •, ' • ,V V i 16.INNER CASING ORTUBING(geothermal'Closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Connie.State.Variance.etc.) ft. ft. in.
3,Well Use(check well use): ft. ft in.
Water Su I Well: 17.SCREEN ..
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
- ❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) tatetial 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 it Bentonite Pour /;13(�d ^
OMonitoring ORecovery ft. ft. ' •` > a ?
Injection Well: ft. fL t
❑Aquifer Rcchargc ❑Groutidwatcr Rcmcdiation pp
19.SAND/GRAVEL PACK(if applicable)• NOV y 11- `. 704
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATF.RIAl. EMPLACEMENT I'IETHn
❑Aquifer Test ❑Stonnwater Drainage ft. ft. I[,`;,.:;,?•:. -c -, -c.I r.,,,
❑Experimental Technology - OSubsidence Control ft. ft. `DI C C 2)
❑Geothermal(Closed Loop) ❑Tracer .20.DRILLING LOG(attach additional sheets if necessary).
FROM TO DE.SCRIP ON(color.hardness.soil/rock type.grain stn.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft it
vies?,
0 ( /'? Sail
4.Date Well(s)Completed: / es , Well/ID# 4344® E3 0 ft. 35 ft f. ..70 taft �`{9I drol f/' opJ 5Ql7
5a.Well Location: ///J li /
. Sd gaunt/gel J ! ,r[�n 4ete <
Icl L.-A Ale 104 One( l�l�s; '4/ 3f ft. 4°i% -A��n;T? Rock
i
Facility/Ownerr. Name Facility)T)k(if applicable)
/J QLS6 hiVS!y/`y/f€6-i ni) t t 11{•3 vI llei, �� a b)41 ft. ft.
Physical Address,City,and Zip .
/71t€k Ien6Vti cow 1 `O 21.REMARKS: •1-(q01 �rCounty Parcel entification No.(PIN� $rl F-6�/�e r+h e'� id ell&rovt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) 22.Certification:
I.
N W I
m
6.is(are)the well(s): fanent or ❑Temporary
a re o ertified 'e I ontrac e D
2-141:?-71
By.signing this form.Iherebv certi r that the well(,)was(were)constructed in accordance with
7.is this a repair to an existing well ❑Yes or 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a cope
If this is a repabt 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 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 l GW-1 is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: e0 05 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@l00') •
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 DWR,Underground injection Control(IUC)
11.Borehole diameter: (in.) Program.1636 MSC.Raleigh.NC 27699-1636
12.Well construction method:Air Rotary
24c.For Water Supply and Opel n=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
13a.Yield(gpm) 07 rriOn4 Method of test:
Air Lift Permit Program,1611 MSC.Raleigh.NC 27699-1611
•
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Racoulces Revised 6-6-2018
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