GW1-2022-00227_Well Construction - GW1_20221216

i
' Print Fol in
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 1'4:WATEWZONEs 1 , -
WellContractorName FROM TO DESCRIPTION -
ft. ft.
2857-A
ft. ft.
NC Well Contractor Certification Number
IS.'OUTER CASING'for multi4aied4*ells);UR LINER if a ilcable
B &K Well Drilling Inc FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 ft' 10L ft' 61/8 !' in' I SDR-21 PVC
16 INNEWCASING_OR TUBING.fixeiathernial closed-loti
2.Well Construction Permit
d // /�. FROM TO DIAMETER THICKNESS MATERIAL
#:(���(� /b���\
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 MATERAAL1
Agricultural 13Municipal/Public it. ft. in.
Geothermal(Heatingicooling Supply) EgResidential Water Supply(single) ft. fa in.
Industrial/Commercial [3Residential Water Supply(shared) is.GROUT
irri ation FROM TO MATE IAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. ON t7It_1(
Monitoring DRecovery ft. ft. i.
Injection Well: ft. ft.
Aquifer Recharge []Groundwater Remediation
19 SAND/GRAVEL;PACK if a `llealile
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage
Experimental Technology [3Subsidence Control
Geothermal(Closed Loop) Tracer >20.ARILIING LOG'attach additional sheets if liecessan
FROM '1'O DESCRIPTION(color,hardn s,su=ck e,pi in size,ere.
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed AA Well ID# 1-3
—5 ft. t.
5a.Well Location:
ft. ft.
achity)O1 vncr Nathe �Facility 1D# 'fapplicablc) ft. ft :,.77 F:7
kY� ��� n�T ft. a V P_ ,�•
Physical Address,City, ft
ity,and Zip // �✓/�n . ft. P i 9
r C>k CAL lit tJ?(C"TZ/ I4 e e'21:REMARKS
County Parcel Identification No.(PIN) {!,,,F+I -a+�� �+ �� -�R17ill
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one laUlong is sufficient) 22.Certification:
N W
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well C ctor Date
By signing this form.I herebv c•ertiJy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or No with 15A NCAC'02C.0100 or 15A NCAC.02C'.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information to rplain the nature q/7he copy of this record has been provided to the aril owner.
repair under#21 remarks section or on the back of this,/onn.
23.Site diagram or additional well details:
S.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 epth below land surface: 1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example- ti Waind 1 @ 100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use"+" 1617 Mail Service Ceritter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection Welts: 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) Method of test: Air Flow 24c.For Water Supply&Iniectiori Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs 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. )
1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016