GW1-2022-00225_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: l
Robert Teague g -14:WATER20YES
Well Contractor Name FROM TO DESCRIPTION
2857-A 344 d ft. 3 S 0ft.
�/Q ft. li7 ft.
NC Well Contractor Certification Number 15:OUTER CASING for:multi "sed wells,OR LINER'`if ilctible:":;
B&K Well Drilling Inc FROM TO DfAh1ETER THICKNESS MATERIAL
Company Name D ft. ft. 1 61181 in- SDR-21 PVC
']6:INNER CASING'OR TUBING eothertaal cltlsedaoo`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,C.aunry•,State,Variance.etc.) ft. ft. in,
3.Well Use(check well use): ft. ft. in,
ter Supply Well: .11 SCREEN, :.:...
FROM TO DIAMETER SLOT SIZE THICKNESS MATER[Al.
gyAgricultural QMunricipal/Public ft. ft. in.
45peothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) -
PP Y( GROUT':'
girrigation FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well:
t. ft.
Aquifer Recharge Grou idwater Rcmediation FROM 19:SAND/GRA A tfaMATERIAL
RAVEL PACK hca6le'
E)
Aquifer Storage and Recovery Salini Barrier EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer 20 DRILLING LGG.attacb'additloualsbeefs:ifne i` ,i ,
Geothermal(Heatin Coolie Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(colon h ness soiVroek type. rein si=a eta
f,. S ft- D
4.Date Well(s)Completed:0`A7---7-_,X�Well ID# S ft. ft.
5aa..Well
`Location: .e�t,t� O G ft.
Fn-w-^�h ��� t l��fi c �fr� C ft ft.
Facility/Owner Name Facility #(if pplicable) Daft. ft
� ft. ft. Imo' ,._.,'-��;-•^' 'n �.5,�..�1
Physical Address,City;and Zip
CL C
County Parccl Identification No.(PIN)
tsrtx
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one lat/long is sufficient) 22.Certification:
N W / �0 y_
6.Is(are)the well(s)oPermanent or OTemporary Signature ofCcrdficd Well Contfctor Date
4v signing this firm,1 kerehv certify that the well(T)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes o 0 with 15,4 NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
ljthir is a repair,full our known well rnnstruction informatio explain lire nature q(the copy ojthis record has been provided to the well ouner.
repair under 411 remarks section or on the back ojthis 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: A SUBMITTAL INSTRUCTIONS
9.Total well dept .low land surface:- (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@00'End 1@100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection 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 constructon method: construction to the following:
(i.e.auger,rotary,rabN direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Flow
13a.Yield(gpm) Method of test: Air 24c. For Water SIIDDIV&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also subriiit lone copy of this form within 30 days of
t 1tz Lbs
13b.Disinfection type: Amount: 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