GW1-2022-00240_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 . . "
Well Contractor Name FROM TO DESCRIPTION
2857-A
NC Well Contractor Certification Number
IS.'OUTER CASING for;malti-ca' :wells.OR LINER'ff a licable.r`
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. t. 6118 in. SDR-21 PVC
-
•16:INNEWCASING:OR Tt;BING. eathermai closed-loo
2.Well Construction Permit#: FROM TO DLAMI;TFR THICKNESS MATERIAL
LLat all applicable well construction permits(i.e.UiC.Cnuury•.State.Variance,etc.) ft. ft. C1 in. '
3.Well Use(check well use): ft. fi.
Water Supply Well: 17.:SCREEN..: :.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agriculttual [)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Su shared —
PP1Y( )
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well: fL ft.
Aquifer Recharge rlGroundwater Remcdiation
19.SANDlGRAVELPACIC(ifa` licab[e `.: :: ,` -':,
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) Tracer �2O..DRILLING LOG.attachaddt'tiohalsheet'i:daeme `'
FROM TO FSCRIPTION(color,d rd s,soilfruckl e, rain size,etc.)
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks) ft. fr. s
4.Date Well(s)Completed: ��a'�- 'ell ID# i t E'er
a.Well Location: ft. fr• C �_
nV_i�srs
Facility/Owner Namk Facili.- #(ifapplicable) it. ft g 7 1+
ft. ft. v•::�����y.�a '� ��' �'
P ical Address,City,and Zip ft. ft (1
21.REMARKS..:,•, .. :' —.. :.: :.:.
County Parcel Identification No.(PIN) (�51rY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica
N W •'� �ZQ"..�
6.ls(are)the well(s)oPermanent or Temporary Si urc of Certified Well Contractor F Date
t3,v.signing this fiorm,I herehv certify that the we1!(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13 Yes o�and�
+vid.15.4 NCAC 02C.0100 or 19A.NCAC 02C.0100 Well Construction Standards and that a
Jf Ibis is a repair,fill out known well construction injormat[oain ilia naa.re gfthc cup+njthc;record inns been prnvided.[n the well owner.
repair under#21 remarks section or on the.back of lhis jor .
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 A GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 11
� SUBMITTAL INSTRUCTIONS
9.Total well bel jow land surface: f 0-5— (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 1 a!00') construction to the following:
i .
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 I'6 1/8 Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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.)
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
he address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 tt2 Lbs completion of well construction tol the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources i Revised 2-22-2016