GW1-2023-01859_Well Construction - GW1_20230222

E.,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague -.14
FROM TO DESCRIPTION
Well Contractor Name 0
f rl
2857-A 7 L V 4— fc ft.
NC Well Contractor Certification Number 15.,O=ItCASING'(for-niultlzcnsedwdls) ILENEBLff' _b THICKNESS
M
B&K Well Drilling Inc FEB 2 2 2023 FROM 1 TO DIAMETERI I THICKNESS I MATERIAL
U a ft ft. 61/8 in, SDR-21 PVC
Company Name TUB
-.1,&OMMOASING.OR ING THICKNESS 2.Well Construction Permit#:-I�VW a�L—od- ZIS FROM I TO _ DIAMETER MATERIAL
ft. ft.
List all applicable well construction pg7nilS(i.e.UIC,County.State.Variance,Tic.)
in.
3.Well Use(check well use):
,17.HSCREEM
Water Supply Well: FROM I TO DIAMETER' SLOT SIZE; THICKNESS L
3Agricultural 13Municipal/Public ft. fr. in
:)Geothermal(Heating/Cooling Supply) EDResidential Water Supply(single)
:]Industrial/Commercial E3Residential Water Supply(shared)
I-Urrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
71 Monitoring Recovery fL
Injection Well: ft.
3Aquifer Recharge IDGroundwater Rcmediation 7 7.9... .
19.SAND/GRAVEL.PACK
Aquifer Storage and Recovery [3Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [:Istormwater Drainage fL fL
Experimental Technology [3Subsidence Control
Geothermal(Closed Loop) [3Tracer 20.'DRILLING LOG(attac additiob2i sheebif necessary)!
(CaWrt13rGneS& fllrocktype,grain size,et
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks)J FROM TO DESCRIPTION.
fL fr.
A.,
4.Date Well(s)Completed: Well 1D# ft, ft
5a.Well Location:
ut) 46SfL 63 f,- L,�,a 0,�- 09
'11
Facility/Owner Name (if applicable) ft. fL
?!A N-19-AA),sd (Q r rr F Is ID" ft. ft. i
V
Physical Address,Citv.and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; -
(if well field,one lat/long is sufficient) 22.Cert
tmTtw4ats, —
6.ls(are)the well(s)o Permanent or [)Temporary X.-niturc of Certified Well Contrael/:
D to
By signing thisfin-m.I hereby cerflj, that the well(,)was(were)conso-ucted in accordance
7.Is this a repair to an existing well: es or dNo with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
ffthis is a repair,fill out known well construcAmbrinafion and explain the nature of the copy oj*rhi.v record has been provided to'the well owner.
repair under#21 remarks section or on the back qf this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also!attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER ofwells
drilled: 4 SUBMITTAL INSTRUCTIONS
9.Total well dWk*below land surface:. 6o (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(&ample-3@200'and 2@1001 construction to the following:
,10.Static water level below top of easing:40 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+- 1617 Mail Service eenter,Raleigh,NC 27699-1617
11.Borehole diameter: 61/8 (in.)
246.For Injection 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.) 1
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
the address(es) above• also subniit one copy of this form within 30 days of
I
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form riW-I North Carolina Department of Environmental Quality-Division ofWatcr Resource; Revised 2-22-2016