GW1-2022-00230_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD (GW-1), For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14 WATER ZONES. % I , 4.
Well Contractor Name FROM TO DESCRWHON
2857-A 6 p ft. 7 d
ft. ft,
NC Well Contractor Certification Number
15.OUTER CASLNG:formultt-cased__ :O&LINER if: Hcablt
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name U ft. ILYS ft. 61181 in, SDR-21 PVC
16 INNER CASING'ORTUBING' eothermal deseddoo
2.We11 Construction Permit#:Cl 20 d a l / S FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,COta7N.State.variance,etc.) ft. Q�K in.
3.Well Use(check well use): ft. In.
Water Supply Well: •. I7.SCREEN ': ._
FROM TO DIAMETER I SLOTSI7E THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal•(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. ft.
Monitoring DRecovery
Injection Well:
ft.
Aquifer Recharge []Groundwater Rcmcdiation fL
19.SAND/GRAVEL:PACK ifs' livable .::
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stotmwater Drainage fL ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal Closed Loop) OTracer -
( P) 20.:DRILLHVGLOG�attach°addl'tionai:'skeets:d.tieces'
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM 'to DESCRIPTION(color,hardness.soiltrock type, rain size,etc.)
ft. ft..
_ l
4.Date Well(s)Completed: b O-� Well ID# Ll 3 ft. ft'
Sa.Well Location: ft• 6 fL
fL f[. ,
Faciliq4bwncr Name —T— Facility iD#(if applicable) ft. ft. ,^°' ,h
-1 1 K) hcS Afeywc r ft. rL ;_a,_pL V F®
Physical Address,City,and Zip ft. ft.
ctak :.:21:REi4IARKS
Q hc�
County Parcel Identification No.(PIN) z rat`��+•.' ��(�rI"�
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certificati
N W �
6.Is(are)the well(s)oPermanent or 13Temporary Signature of Certified WeTI Contractor Date
Av signing this form,1 hereby certJy that the well(s)was(were)consnveted in accordance
7.Is this a repair to an existing well: [)Yes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
lfth&is a repair,fill out known well construction information and explain the nature gfthe copy of this record has been provided to the well owner.
repair under 421 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages if necessary.
drilled: Jl
��� SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
I
10.water Static v water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If wares level is shove casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$
(1°) 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Air Flow 24c.For Water Supply&Iniection 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 1/2Lbs completion of well construction to;the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016