HomeMy WebLinkAboutGW1--06742_Well Construction - GW1_20241112 iI
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Joseph Bailey .. 14.WATER ZONES I I .
-FROM TO DESCRIPTION
W cIl Contractor Name 1 R oft fry $ft- Me e I r1-4 c-Thr wife
3271-A 4C'iI /Ng"-xi
I'
Well Contractor Certification Number t 11 ft �_ I.I frgc12',eAwe-
NC
15.OUTER CASING(for multi P-caseed Weellls)OR LiNER(f ap livable)
B & K Well Drilling Inc FROM TO DIAMETER I THICKNESS MATERIAL
® ft. la-ft 6 1/4 i"• SDR-21 PVC
Company Name , •
n•„ ®� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: r 44 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.State.Variance,etc.) ft. tt i in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO ,DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.,,
OGeothermal(Heating/Cooling Supply) Sirgrdential Water Supply(single) ft ft. in.;
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
0 Irrigation ❑Wells>100,000 GPD FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft Bentonite Pour
OMonitoring ❑Recovery ft. ft I. -.. =••4 • .6 :'''';
injection Well: ft. ft. i
I
❑AquifcrRcchargc ❑GroundwatcrRctncdiation I
19.SAND/GRAVEL PACK(if applicable) NOV 9 /Itii1
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHDOD'
❑Aquifer Test ❑StormwaterDrainage rt. ft In`.-3:7;-4.".='-;'r-^ -.:'-_-+?!���
❑Experimental Technology ❑Subsidence Control ft ft. 1) V';.c i.:a
❑Geothermal(Closed Loop) OTracer 20:DRILLING LOG(attach additional sheets if necessary).
FROM TO DESCRIPTION(color.hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft ft
iire;;I?„ Joil
4.Date Well(s)Completed: 1D// /2% Well iD# L67-!6, C� ft. /0 ft. med.
/�., f? 'i/C
5a.Well Location• ( 6 ft p o esfit e'k I; o/"e`•'/t t<
C9 r95 �i t ULG 0 1,j14firs dr e ft. 7J fL ,
Facility/Owner Name `� { }Facility ID#(if applicabllee)) /�/� ft. ft.
S 0 I/ aria !0 de ,,J(4'i,f my VC. A//,7 y ft. ft.
Physical Address,City,y,and Zip ! ft. ft
®La ✓i (Os loll/ O S' 21.RE1tifARKS ( " /
County Parcel Identification No.(PiN) Lif '
/ .•lire I -e of °1C�•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: & tires 5.' .
(if well field,one lat/long is sufficient) 22.Certif ation:
N W •
I 1W2_,. _
Si azure.Cent ied Well Co etor Dat
6.Is(are)the well(s): ermanent or ❑Temporary• 7
� p signing this form.Isere cert?'thhat the well(s)was(were)constricted in accordance with
❑ �
7.is this a repair to an existing well: Yes or i V 15.4 NC4C 02C.0100 or 1 A NCAC 02C102011 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 421 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 deeded. indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: I'
9.Total well depth below land surface: o5"r 24.SUBMITTAL INSTRUCTIONS(ft.) Submit this GW-1 within 30 days df well completion per the following:
For multiple wells list all depths if different(example-3L 200'and 2(4100') 1
10.Static water level below top of casing:40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR).
lfrrate,•level is above casing.use"+" • information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
i
11.Borehole diameter 6 /�$ (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 departtrient of the county where installed
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
��j Air Lift Pennit Program,1611 MSC,Raleigh'NC 27699-1611
13a.Yield(gpm) t/° f Method of test:
13b.Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018