GW1-2022-00248_Well Construction - GW1_20221216

Print Form
WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER:ZONES..
Well Contractor Name FROM TO DESCRIP;rION
2857-A 56 ft.
NC Well Contractor Certification Number
15:OUTER CAS1NGi for'multi,ccaged::wells;OR=LINER:if a llcahlc
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name D f1. ft. 61/8I in. SDR-21 PVC
46.INNER CASING OR TUBING" edthermahclosedb16o
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL "
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) R. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS 11ATERIAI.
Agricultural [3Mtmicipal/Public ft. ft. •in..
Geothermal(Heating/Cooling Supply) OC Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) IS:GROUT
rz
Irri ation FROM TO MATERIAL `EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring ORecovery
Injection Well:
Aquifer Recharge OGroundwatcr Rcmcdiation
19.SANDlGRAVEL:PACK if.a' licable -... ,. ,. • ;-;
Aquifer Storage and Recovery ©I Salinity Barrier FROM TO MATERIAL EMPLACEi11ENT METHOD
Aquifer Test [DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20;DRILLING 1:0G aftacli additional shee(i if oecessar"
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM 1'O UFSCRIP PION(color,ha
s,soiUrock type,+coin size ere.) '
ft. L ft.
4.Date Well(s)Completed:�=y_17 Well ID# 7 ft. ft.
5a.Aell Location:
ft. ft. '
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft.
ft. ft.
Physical Address,City,and Zip I _
b J r, �c)�y 21.REMARKS. —
County � Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;
(if well field,one]at/long is sufficient) 22.Certifica
N W
6.Is(are)the well(s)oPermanent or OTemporary Sigfiature of Cc icd Well Contraci Date-
,
fi�tt-� By signing this farm,I hereby certify that the imll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or with 15A NCAC 01C.0100 or 1 SA NCAC 02C.0200{yell Construction Standards and that a
/'this is a repair,fill out known well construction information qdd ex ain the nature of the copy of this record has been provided,to the well owner.
repair under#21 remarks section or on the back of'this form. i
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2 ct/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 Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
12.Well construction method Air Rotary above,also submit one copy of this form within 30 days of completion of well
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) Air Flow
Method of test: 24c. For Water SuoDly& 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: t t/z Lbs completion of well construction to' the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resour I ces Revised 2-22-2016
'