GW1--06741_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey • 14,WATER'ZONES I I •. •
Well Contractor Name FROM TO DESCRIPTION
3271-A QO ft. �t �ft' S./44/( f5 -T .zd'7-e
f 7
NC Well Contractor Certification Number gft. /ao ft. c�9,// ��'G'` re��rn5
• 15.OUTER CASING.(for mulli.cased,wells)OR LINER(if at)licable)'.',
. B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' rJ ft. 6 1/41. in• SDR-21 PVC
G`J• ' .16.INNER CASING OR TUBING(geothermal doted-loop) .
2.Well Construction Permit#: (-OP �!3 3 / FROM TO DIAMETER THICKNESS 1 MATERIAL
List all applicable well construction permits(i.e.U/C.County.State variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in. .
Water Supply Well: 11 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munici al/Public it. ft. in.
❑Geothermal(Heating/Cooling Supply) srdential Water Supply(single) ft. ft. !n.
I
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METHOD& PUNT
ft
Non-Water Supply Well: 0 , 20 ft, Bentonite Pour 9qJ'i5' $ P
❑Monitoring ❑Recovery ft. ft. V
Injection Well: ft. It. 1.. "' `--•.a--,
❑Aquifer Recharge ❑Groundwater Rctncdiation 4 4 ;_., ' - ; ""' -
19.SAND/GRAVEL PACK(If applicable)• ''-'''2:-.. ,/.'"-•J i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO 11ATr,R1AL F.IktiCy..MENT METHOD- ts.,..'
DAquifer Test ❑Stormwater Drainage ft. ft. I, U V I 9 inn
❑Experimental Technology ❑Subsidence Control ft. ft. ;` Ic'.,...._,.,..,-• ."
❑Geothermal(Closed Loop) OTracer .20:DRILLING LOG(attach additional sheets if necessary).(•:,:i• :`'4.'`e ?C,;,,
FROM TO DESCRIPTION(color.hardness.sodiediktype:''rain size.etc.)'•''
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. f! ft. ip. fail
4.Date Well(s)Completed: ld/b7�d y Well ID# . ft. aU°ft 1 !bars,'' ,S'gg4
Sa.Well Location: p? n Left e '13� i wi .C44 s0-�
r ft ft T Rock
SaMQn� cartdl1 sff�Jler4l � ys� �� /�� avail.? k
Facility/Owner,Namme /(�� Facility�'fD#(ifapplidaab`lle) f� i'it• gat' 4:449,7'R t.
�5' I ral leer /Ctrsa Wood Leg IN(/o67 ft, ✓ ft Y"
Physical Address,City, d Zip / ft, fL
Rea/4 4 ea Lill /01 '21.REMARKS' / : .
County Parcel Identification No.(PiN) 3 ffCent-- 61 We/ 1,v 30 t/A6'4/-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) / ertifienttor
cation:
N W D
6.1s(are)the well(s): rmanent or OTemporary Date
is/onn.1 herebv c rr(h+that the wear)was(were)constructed in accordance wish
7.is this a repair to an existing well: ❑Yes or phi-- 15.4 NC.4C 02C.0100 or ISA NCACO2C.0200 Well Consultation Standards and that a copy
if this is a repair.fill out known well construction information and explain the nature of'the alibis 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: (ft.)
For multiple wells list all depths if different(example-3®200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:40 (ft) 24a. For All Wells: Original I form to Division of Water Resources (DWR).
if ate,•level is above casing.use"+'• information Processing Unit,1617',MSC,Raleigh,NC 27699-1617
11.Borehole diameter:_6 1/18 (in.) 24b.For Injection Wells:Copy to DWR.Underground injection Control(TUC)
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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing;over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) '�'-M
��f�ethod of test:Air Lift Permit Program.1611 MSC,Raleigh.NC 27699-1611
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-1 North Carolina Department of Environmental Quality-Division ot•Watcr Resources Revised 6-6-2018
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