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HomeMy WebLinkAboutWELL-09-2022-181281.TIF Print Form 4 WELL CONSTRUCTION RECORD (CW-I) For internal Use Only: "" 1.Well Contractor Information: Joseph Bailey 14.WATER ZONES Well Contractor Name FROM 10 DESCRIPTION 3271-A a5-d ft. 241 ft. s„? if f-,(rt„c 26v-c NC Well ConhactorCertificationNumber .31oft. 3/aft• M4J i-r zone 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) • B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL Company Name 0 n. 77 ft. /_-'�-- In. !J D ,y j /.{e. ! 16.INNER CASING OR TUBING(geothermal,540 dosed-loop) r�/ 2.Well Construction Permit#: L/`1)9 '.?Qz2• I y/ g FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft. ft. in. 3.Well Use(check well use): ft. ft, in. Water Supply Well: 17.SCREEN • FROM TO DIASIETER SLOT SIZE THICKNESS MATERIAL ©Agricultural °Municipal/Public ft. ft. in. °Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in. °Industrial/Cotnmercial °Residential Water Supply(shared) 18,GROUT • hlmgation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT- Non-Water Supply Well: 0 ft. Y0 ft. Denote Pour 0 Monitoring °Recovery ft. ft. Injection Well: uifer Recharge ft. ft. A q g °Groundwater Reinediation Aquifer Storage and RccOve 19.SAND/GRAVEL PACK(if applicable) ty °Salinity Barrier FROM TO MATERIAL __ EMPLACEMENT METHOD °Aquifer Test 0Stotmwater Drainage ft. ft. °Experimental Technology °Subsidence Control ft. ft. °Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) °Geothermal(Hcating/Cooling Return) °Other(explain under#21 Remarks) FRont TO DESCRIPTION0 ft. /0 ft. /74 SCNIP{TION 5 a(color,hardness,solVrock ape,groin size,etc.)evilJ 4.Date Well(s)Completed:J/V/A3 Well ID# Lai" 63 /0 ft• 30 ft. nli fRi 50i/ 5a.Well Location: 30 ft. bcrt. Yi/O2,/ Bros.» sf4,a`/ /09-Ni/a70,‘Le ti///,S/j icf 5"/ 6 ft. S'�-ft. Slfr Rock. Facility/Owner Name Fac try ID#(if applicable) f1 ' ft, Lr Tit. 6f�IT6 ?6,4`� 3,V/0 rin&c RuP/LA/ l 74;dot A/C.20G0 (r ft. I'hysical..Address,City,and Zip / �j/- p n ft. ft. L'f�'/i L✓ijC� C� �G9$0 11/4 957 21.REMARKS County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one let/long is sufficient) 22.Certifica 'on: N W "1 c p�7 6.Is(are)the well(s) Permanent or OTemporary Sign re of ificd Well Contrac . . B signing this finis, /hereby cerlii.•that the well(al was(were)constructed in accordance 7.is this a repair to an existing well: Oyes or Elf No with 15.4 NCAC t12C.0100 or 15,4 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 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: Youmay use the back of this page to provide additional well site details or well 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled:' l'a�t SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: y (it•) 24a. For All Wells: Submit this fors within 30 days For multiple wells list all depths ifdi1Jerent(example-3@200'and 20100') of completion of well construction to the following: 10.Static water level below topof casing: 40 If water level is above casing,use (ft. ) Division of Water Resources,Information Processing Unit, 6 1/81617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter. (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a 12.Well construction method: i?O n ry above, also submit one copy of this form within 30 days of completion of well (i.e.auger,rotary,cable,direct push,etc.) construction to the following: FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) !! Method of test: Airlift 24c. For Water Supply& injection Wells: In addition to sending the form to Chloe Tabs t 1/2 Tabs ob. the address(es) above, also submit one copy of this form within 30 days of b.Disinfection type: Amount: completion of well construction to the county health department of the county where constructed. Fonn OW-I Nonh Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016