GW1-2022-00229_Well Construction - GW1_20221216

. .rl ID 6 3 ZZ �Pnnt Form -
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor information: i
Robert Teague =14:WATERZ01VEs " , '.
Well Contractor Name FROM TO DESCRIPTION
2857-A 01 6 o ft. raft.
ft. ft.
i
NC Well Contractor Certification Number 1s.'OUTER CASING for:mtilti casedlwells OR LINER;ifa ticable
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
ft. ft. 61/8 1" SDR-21 PVC
'
2 q 1 U 16.INNER CASING.ORTUBING; eothermal closed400
20 2.Well Construction Permit#:C) , ' 'a ' 1 0) S 9 FROM TO DIAMETER THICKNESS MATERIAL +
List all applicable well construction permits(i.e.UIC,County,State.Variance.etc.) O rt. a ft. Q�-( in.
3.Well Use(check well use): ft. ft. -in.
Water Supply Well: T SCREENGi?' .,
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public ft. ft. iu•
Geothermal.(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
Irri ation FROM TO MATERIAL ENIPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Rcmcdiation
Aquifer Storage and Recovery (Salmi Barrier 19 SAND/GRAVEL,PACK da "liable'
q g ry ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology 13 Subsidence Control
Geothermal(Closed Loop) Tracer •21MRILLINGLOG attach`additionalsheeNifnecessa
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) I
FROM To DFSCRIPTION(color,hardness•soitimck type,gmin size•etc.)
ft. ft.
LA
4.Date Well(s)Completed: b -z�Well ID# L ft. ft. I r
Sa.Well Location: �
ft. 6
ft." a
Facility wner Name �— Facility iD#(if applicable) ft. ft.
3L1 1 K)h c S NV'e "&/c ft. ft.
Physical Address,City,ancrZip ft. ft. s ti s F,"< tb<_s er a_L•nr'
GAT 21:REI4IARx5,.
L
County Parccl Identification No.(PIN)
IRS iii. ;1D 1 i�f. 3 nit
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: R
(if well field,one latlong is sufficient) 22.Certificati
N w
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Ael Contractor Date
4v signing/his form,I herebv cerlify 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 NCACO2C.0200 Well Construction Standards and that a
If This is a repair,fill out known well construction infrnrmalion and explain the nature elf the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 1
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I / SUBMITTAL INSTRUCTIONS
�b 9.Total well depth below land surface: _5 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdIerent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below to 40
p of casin g: (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 Iniection 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.) p
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&Injection Wells: In addition to sending the form to
Chlor Tab 12 Lbs the address(es) above, also submit one copy of this form within 30 days of
s 1 /
13b.Disinfection type: Amount: completion,of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division or Water Rcsourccs Revised 2-22-2016