GW1-2022-00007_Well Construction - GW1_20221216

.Pent Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES: G i
Well Contractor Name FROM TO DESCRIPTION
2857-A it. L ft.
ft. ft. 11
NC Well Contactor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
B.&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 10 ft. 1 6118 in. SOR-21 PVC
tt 16.INNER CASING.OR TUBING� eiathermahviosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS •MATERIAL•
List all applicable well construction permiri(.e.U1G County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fit. fit. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaL/Public ft. ft. in.
Geothermal(Heating(Cooling Supply) OResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial PPY(
Residential Water Supply(shared)
..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. IL
Monitoring 13Recovery ft. ft.
Injection Well:
fit. fit.
Aquifer Recharge DGroundwatcr Rcmcdiation
19:SANI)IGRASYEGPACK fa IIcsble`:. : .'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer '20.DRILL LOG attach additional sheets if[feces
FROM •1.0 DESCRIPTION(color.ha ness soiUrock tr e, rain size,etc.)
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) ft. t. '
17)
4.Date Well(s)Completed: - Well ID# 6
5a.Well Location: fit. ft.
LCML 5QC" ft. ft
Facility/OwncrName Facility lD#(ifapplicablc) ft• ft
ft. fL
Physical Address,City,an Zip ft. ft
s:21.-REMARKS
County Parcel Identification No.(PIN) iffiGi'Ff:dad. ) i 1 �Ur'1i1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certific gg
N W000l.
6.Is(are)the well(s)oPermanent or 131remporary Si Lure of Ccnificd Well Contractor' Date
4%-signing this form,l hereby certi)p that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or 0 with 15.4 NCAC 02C.0100 or 15.4.NCAC 01C.0200 Well Construction Standards and that a
Irthis is a repair,fill out known well construction information a ain the nature nfthe copy ofihis record has been provided to the well owner.
repair under k11 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ! SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(arample-3@260'and 1 a 100') construction to the following:
10.Static water level below to 40
p of casin g: (fit.) Division of Water Resources,Information Processing Unit,
Ywater level is above casing,use 1617 Mail ServJict Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy,of this form within 30 days of completion,of well
12.Well construction method
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) -V� Method of test: Air Flow 24c.For Water SuoDiv&lniection Wells: In addition to sending the form to
the address(es) above, also ',submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 112 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016