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Home My WebLink AboutWELL-05-2022-171234.TIF i? r I�1'�-i. WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: Joseph Bailey . i4:WATERZONES • Well Contractor Name FROM TO - DESCRIPTION 3271-A q 57 ft, q ft, 3/�1 y/t ff e c hwe .26rRC R. ft. NC Well Contactor Certification Number ::15::OUTER CASING(flit mi lti-cased wells)OR•LINER(N le) B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL. Company Name coft. ea:. ft. /.aC t In. op ^]i Fife.16:.INNER.CASINGOR,TUBING(ggeothertnali7:ciithedd4000lp) ,,':a 2.Well Construction Permit#: well.-s II �0 jtr'`7A. FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft: in 3.Well Use(check well use): ft' ft' in. Water Supply Well: •17.:SCREEN .. .` FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ©Agricultural DMunicipallPublic ft. ft. in. ]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft, la. Dlndustrial/Commercial OResidential Water Supply(shared) r 18 GROUT "Irrigation FROM TO MATERIAL ti EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: o ft 20 fL Benote Pour r�g4rfjr7/' Monitoring (Recovery H. ft. '✓ • Injection Well: tt 0 Aquifer Recharge OGroundwatcr Remediation 79:SAND/GRAVEL PACIG(ifspplksble) ''Er' t+tee`; .Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test DStormwater Drainage ft. ft. ,DExperimental Technology oSubgiderice Control ft. ft. Geothermal(Closed Loop) OTracer 20:DRILLLNG LOG(attaeh-additionalsheetd'.N tieievsary) FROM TO DESCRIPTION(color.hardness.soil/rock type,groin size,etc.) E3Geothermal(Heating/Cooling Return)fn ❑Other(explain under#21/_Remarks) ft, /� g, f?C� s O�j 4.Date Well(s)Completed:J/a //a s3 Well ID# GD.6 4 .5 ft. /3 c ft' pl i.et/ Soil { 5a.Well Location: 3C ft 47 ft' re/44, erok,// 5'a ai . , 7 4L � Le <!. GnS ft, t�5- ft. t Lira4i 44n sell Facility/Owner Name Facility'Da(• a able) /SfL r ft. i P? gO`/c // 3129�>iier/?0L� �fi?JM/VG. 07gkS VS—ft' go it' - a•-ii t< '( ft. Physical Address,City,and Zip E'a w4 Co. 33G 1,egipi,a fa rf 21:tEMARKS•.. , .: ,.: : . . . County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell.field,one lat/long is sufficient) 22.Certification: N W 11d' ' 40' - / 0/244Z 1 6.Is(are)the well(s)13Permanent or OTemporary tore of rtificd •ell Cootrac,,r Dat y signing thic farm,I hereby e t(that the well(s)was(were)constructed in accordance i 7.Is this a repair to an existing well: Dyes or ION° with I5A NCAC 02C.0100 or A NCAC 02C.0200 Well Construction Standards and that a If this is a repair,fill out known well construction information and explain the nature of the copy of this record hat.heen 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 site details or well construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled:' SUBMITTAL INSTRUCTIONS �(� 9.Totai well depth below land surface: r/ (a') 24a. For_All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: 10.Static water level below to of casin 40 p g: (ft.) Division of Water Resources,information Processing Unit, If water level is above caring,use'•+•• 1617 Mall Service Center,Raleigh,NC 27699-1617 i 11:Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a . r above,also submit one copy of this form within 30 days of completion of well I 12.Well construction method: . I 1 Of 4 9/ construction to the following: (i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) I Method of test:Airlift 24c.for Water Supply&Injection.Wells: In addition to sending the form to ChIOr Tabs 1 1/2 Tabs the address(es) above• also submit one copy of this form within 30 days of 13b.Disinfection type: Amount: completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina De artment of Environmental Quali ty-Division of Water Resources Revised 2-22-201 6.