GW1-2022-00243_Well Construction - GW1_20221216

;Pent To
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I
1.Well Contractor Information:
Robert Teague 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2857-A /S 44
NC Well Contractor Certification Number V ®!
lg;OOTER CASING f u cased lls OR LINER if a doable
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 11. J ft 6 118 in. SDR-21 I PVC
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lis[all applicable well construction permits(i.e. UlC,C'otarty,State,Yuriunc e,etc.)
it.
3.Well Use(check well use): ft. ft. in.
ilrrigation
ater Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in•
Geothermal(HeatinglCooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 3ti.GROUT`
Geothermal
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery
Injection Well:
ft. ft. l
Aquifer Recharge E)Groundwatcr Remcdiation
19.SAND/GRAVEL PACK(if applicable)
..
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®I Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolie Return) Other(explain under#21 Remarks) FROM . •1.0 DESCRIPTION(color,ha ess.soillrock type, rain size•etc.)
1 O ft. I I 17ft.
4.Date Well(s)Completed:)- ! `t ell 1D# S ft ft.
5a.Well Location: ,) �__5 tt.
317 _S- t I_S
Factlit l;bwwncr/N'ame ` •JJ Facility ID#(if ap�p�l�icablc) ft. ft.
Ph -'cal Address,City' P ft.and Zip ft. 5
d �'t. "� n�� •4' h v �
21.REMARKS
J' l f• ^
County Parcel Identification No.(PIN) DEC 1 6 707?
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one laUlong is sufficient) 22.Certific 'on: 01'a'LZ/u:�ts
N W
6.Is(are)the well(s)OPermanent or Temporary ignaturc of Certified Well Con[ for Date
4v signing this farm.I herehv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or No with 15.4 NCAC 02C.0100 or 15A iyCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill but known well construction information plain the nature of the copy nf'rhis record has heen provided to the well owner.
repair under#21 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
C SUBMITTAL INSTRUCTIOii S
9.Total well pth below land surface: ) (ft-) 24a. For All Wells: Submit:this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(exampTe-3^2,200'a7td 2 a 100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use '+" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (in.)
24b.For Injection Wells: lnladdition 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 ] `ee-Centgr;Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water 5t rily 2�Ttitrcti, Wells:•;In addition to sending the form to
ChlorTabs 1 vzLbs the address__{e�,j:abil o-_s i�;ai sane copy-;of this form within 30 days of
13b.Disinfection type: Amount: completiolvzow, Emotion7`to the county health department of the county
where constructed
e _
Revised 2-22-2016
Forth GW-I North Carolina Department of EnY'renmcntal Quadiy-Division of IiTCr Resoutresr