GW1-2023-01861_Well Construction - GW1_20230222

WELL CONSTRUCTION"CORD(QW-1) For internal Use Only:
1.well Contractor Information:
Robert Teague
1.!KA77-77 7
Well ConuactorName
FROM TO DESCRIPTION
2857-A I C) ft. ft.
------------ VE-r-
NC
well contractor"�""'Numb- FEB 2 2 2023-
B&K Well Drilling Inc 15-,0UMR CAS
FROM
-
bl- DIAMETER, THICKNESS MATERIAL Uompany Name 0 it. ECI SDR-2161/8 '
PVC
2.Well Construction Permit# 1&RiNEkCASJNG*0RTl ING dother,1121-4
List all applicable well construe)/onFROM TO
K IMATERIAL
County, rate.Variance, (c.) ft. ft. THICKNESS in.
3.Well Use(check well use): ft. I .
n.
15"i
Agricultural FROM TO DIAN-TE `R:' -SLOT.S.[Z.E
[)Municipal/Public ft ft. in..
THICKNESS RIAL
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single)
Industrial/Commercial 13Residential Water Supply(shared) .,18., ft ft. in.'
Irri ation
OM
Non-Water Supply Well: TO MAT RIAL
FL fL 0
—DRecovery
Injection" Well: ft. ft.
Aquifer Recharge DGroundwatcr Rcmcdiation ft.
Water
A
G Im
0
e
d 0_W
u c s
S
u e
In
t.0
Non-Water
Monitoring
g
n
Geothermal
Industrial/Commercial p
W
p
a
C S
y 0 u
II(H m p
Well:
P
e r Recharge
Aquifer
if Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRA L PACK(If2pplicabli,
Aquifer urf T FROM TO .........
er " -EMENT METHOD
quifer Test []Stormwater Drainage It.
T
Experimental. Technology E]Subsidence Control ft.
Geothermal(Closed Loop)
", I( OTracer 20 DRILLING LOG . .....
Geoth G a ch addithihil s�
a Ha FROM TO
nal(He ing/Cool ng Return) ElOther(explain under r#21 Remarks) ESCRIPTIUN(COIGR*2rdness.soilfruck!yae, �n
ft.
4.Date Well(s)Completed:k� Well W# ft.
ft.
e-
5a.Well Location: ft.t. CIA
2.1- f4 fL
r-ulmytLiwner Name Facility ID#(ifapplica ft
ft. ft.
Physical Address,City.and Zip ft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lattlong is sufficient)
22.Certifl
N
6.Is(are)the welf(s)oPermanent or oTemporary
Date
7.Is this a repair to an existing well: [3Yes or Br Signing Mir form,I hereby cert6fi;-that the well(r)war(were)constructed in accordance,
'ONo wirh 15.4 NCA C 02C.0 100 or'i5.4 kA C 02C.0200 Well ConstructioStandards and that a
!'this is a repair,fill out known well construction information finaVrplain the nature ofthe copy ofrhis record has been providedto the,well owner.
repair under#21 remarks section or on the back of this form. x
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-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attich additional ages ifnecess drilled*_ p ary.t.1 SUBMI 'TAL INSTRUCTIONS
9.Total well de below�1..d surface:
--5h <
For multiPle wells list all depths ifeliffereat(era�P, 3@20�0,
and �100,) �(ft 24a. For All_Wells: Submit this fbim within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40
lfwarer level is above casing.use Division of Water Resource I s,Information Processing Unit,
.61/8 1617 Mail Service Cente'r'l Raleigh,NC 27699-1617
11.Borehole diameter:
—(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
(i.e.auger,rotary,cable,direct push,Tte-5 construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,UndeIrground Injection Control Program,
1636 Mail Service Center,iRaleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow I !
—3— 24c.For Water Supply&IpLection Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs the address(es) above, also submit one(copy of this form within 30 days of
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