GW1-2023-01910_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague
14.WATER ZONES".:-.:.z;�
Well Contractor Name. FROM TO DESCRIPTION
2857-A
• NC Well Contractor Certification Number
1S.:OUTER'CASING'fariuul . iid:rrells ORLtNER'ilia liable .......;
B &K Well Drilling Inc FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 ft ft. 6118 f I in' SDR-21 PVC
16:1NNER G G OR TUBING eotiierival etiised-I
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State,Yariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '17..SCREEN•'
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(Single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
PP Y ) S.GROUT:—%
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: ft. fL
Monitoring Recovery ft. ft
Injection Well:
ft. ft. P
Aquifer Recharge Groundwater Rcmcdiation
19.SAPID/GRAVEL PACK da Ucable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage fL ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer '20.DRMLING LOG attach 2dditioa21 sheets if ttiar
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardnm soilfrock type,,•in size.etc.)
It. ft.
4.Date Well(s)Completed: I- (, - a Well ID# ft ft. � I 42-
5a.Well Location:
Facility/Owner Name Facili ID#(if applicable) ft. ft.
L ft. ft. �
Physical Address,City,and Zip ft. ft. �,
I W.
County Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Dira'0ici0G
(if well field,one lat/long is sufficient) 22.Cert ado
N W
6.Is(are)the weli(s)oPermanent or OTemporary Signature of Certified Well Con ctor Date F-
4v signing this(urn,I hereby certify that the well(.)srav(wen)constructed in accordance
7.Is this a repair to an existing well: []Yes or Na u•irk 15.4 h'C.4C 03C.0100 or 15A NCAC 01C.0200)Veil Construction Standards and that a
Ifthis is a repair,fill out known well construction information ak_d�atplain the nature of the cops of this record has heen provided to the well o nner.
repair under 021 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: it
n SUBMITTAL INSTRUCTIONS
9.Total well depth be ow land surface: �l Y (fI) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple wells list all depths if different(example-3@100'and 1@100� construction to the following:
10.Static water level below to of casin 40
P g� (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 1/8 (in.) I
24b.For lniection 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
,
r e auger,rotary, construction to the following:
('. . g tary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Celnti r,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Suoah•&lniecdon Wells: in addition to sending the form td
the address(es) above. also submit;one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1t2 Lbs completion of well construction to f the county health department of the county
where constructed. l
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revisod 2-22-2016