GW1--06740_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Joseph Bailey 14.WATER ZONES
WellFROM TO DESCRIP,T1ON
Contractor Name
3271-A J10 ft. /X ft. All PPEGI e 2t,
ft. ft.
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. ft- 61/4 •i"• SDR-21 PVC
Company Name • . I .16.INNER:CASING ORTUBING.(Reothermal closed-loop)• '
2.Well Construction Permit#: CAP- �10 �l® . FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C.County.State.Variance.etc.) ft. ft. in.
ft. ft. in•
3.Well Use(check well use):
Water Supply Well: • • 174:SCREEN
PPY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft it. in•
❑Geothermal(Heating/Cooling Supply) 11,Pateial Water Supply(single) rt. 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- Bentonite Pour /cds//
❑Monitoring ❑Recovery ft. ft.
• injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rcmediation
19.SAND/GRAVEL PACK(if applicable) ••+ ' •.'•7.'-_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD .i r
❑Aquifer Test ❑Stormwater Drainage ft. ft. „ NO 1
❑Experimental Technology ❑Subsidence Control ft. ft. t.��
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach`additional sheets-if&6ec"ehsary)".'.'1-.?-r.I-.,.=.>_: .`.
FROM TO DESCRIPTION(color.hardness.soiltrock type,gia "iii size,:eta)Yt::.
❑Geothermal(Heating/Cooling Return)
5 ft') ❑Other(explain under#21 Remarks) a 1L dsft. ?ctA cii
�
4.Date Well(s)Completed: S-/'O Well ID# /5ft /�3fa y/e'1 5,�6 '
L
Sa.Well Location: 6 f` yen/ati J rem/ .Soil
.�_r
1 mi5e- /)ft- 7 c ft. kriy
ig� ri $ 0-ik (V.5 Oil
Facility/Owner Name Facility iD#i(if applicable) •
5"ft• �f1(]r ft.r 14V/1Q (�,/�fri,� /?Q_/ek
a)&S' t/mbe.rQ yet' Cle�1' A/C 0[!o, Is-fL tdlf aJ L 6.rafq i22 !1! �4lY
Physical Address,City.and Zip J ft ft.
l Wag CO,C 3-321- Olt
2 21.REMARKS '
County ' Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: j.
(if well field,one lat/long is sufficient) 22.Certific '
N W I.
6.Is(are)the well(s): ermanent or ❑Temporary Sat a fCe 'red Well rtractor 170124
By going this form.ihereby eertif+that wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lNo / 4 NC4C 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a cope
If this is a repair.fill out known well construction information and explain the nature of the a his 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:
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: f 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:(ex (ft.) Submit this GW-1 within 30 days of well completion per the following:
For nmltiple"ells list all depths if d eren((example-3@2J2� '
nd 2(a1100')
24a. For All Wells: Original"form to Division of Water Resources (DWR).
10.Static water level below top of casing:40 (fL) lnfoimation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
11.Borehole..diameter:6 1/18 (in.) 24b.For Injection Wells:Copy tb DWR,Underground injection Control(NC)
Program.1636 MSC,Raleigh.NC 27699-1636
12.Well construction method:Air Rotary 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
13a.Yield(gpm) 3® -r Method of test:
Air Lift Pennit Program,1611 MSC,Raleigh.NC 27699-1611
Chloe. Tabs 1 1/2 Lbs
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Rccourccic Revised 6-6-2018
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