GW1--03371_Well Construction - GW1_20230515

WELL CONSTRUCTION RECORD GW-1
For Internal Use Only:
1-Well Contractor Information:
Robert Teague
Well Connector Namc `14:WATER"ZONES
2857-A FROM TO DESCRIPl'ION
NC Welt Contractor Certification Number tt• fL
B&K Well Drilling Inc 15c0UTERGASING formulUi CAsed:We1►s ORLINER:' 'S'ilcatil0
FROM TO_ DIAMETER -Company Name THICKNESS MATERIAL
/� 61/8 in. SDR-21 PVC
D iL � ft.
z.Well Construction Permit#: ' CJ 3J7 7 -=16 INNER CASING OR TUBING.
List all applicable well construction permrts(r.e. IC,County.Slate.Variance.etc•.) FROM TO thermal
elosed.l`
--r— DIAMETER THICKNESS MATERIAL
ft. ft. in.
3.Well Use(check well use):
Wel ft. ft. in.
Water Supply l:
Agricultural E)Municipal/Public FROM TO DIAMETER SLOTS17E THICKNESS MATERIAL
Geothermal(Heating/CoolingSupply) fL fr in.PP Y) oResidential Water Supply(single)
Indus triaUCommercial Residential Water Supply(shared) fL ft in.
Irri anon PP Y(s ft GROUT
Non-Water Supply Well; FROM TO MATERIAL EM1IPLACEMENT METHOD&AMOUNT
Monitoring it• ft
Injection Well: 13 Recovery
ft. ft
Aquifer Recharge DGroundwatcr Remcdiation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19 S /GVEL;PACK rfa cable
Aquifer Test �f, FROM To MATERIAL
Experimental Technology ;
t_I Stormwater Drainage ft. EMPLACEMENT.MET HOD
tt'
OSubsidence Control
Geothermal(Closed Loop) Tracer ft tt.
Geothermal(Heatin Coolie Relum II LLY I OG'attach"silditfoiiai sheets'ifue
Other(ex fain under#21 Remarks)
FROM FROM TO
o DFSCRIPTIOh(rnloq h nps soiUrock nln ��)
6 f4 ft.
4.Date Well(s)Completed:`�i �� Well ID# < '
fL
Sa.Well Location: O
ft. 30 fL h
fL as ft.
Facilrty/pwncrNamc FactlttyID;#(ifapplicablc) ft. ft.
v�••ice„� r 'i.: ice•-
ft.
Physical Address,City.an Z ft.
n
Y ft. ft.
21:RE1tiiARgB
_ J
aunty
Parcel Identification No.(
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certific
N
W 3_�^
6.is(are)the Well(s)
oPermanent or oTemporary gnaturc ofccrtificd ontmctor
Date "
7.Is this a repair to an existing well: Yes or By'signing this farm,I herehv cent that the xeI!(sJ was(k'ere)constructed in accordance
wit/jth[s is a repatr Jill our known well constructioninformation d Np[ain the nature uj[he Ph 15A N m Ord hash 00 Or provided15 ,the well.0200 We[!Cmutruction Standards and that a
repair under#21 remarks section or on the back of this form. to
agram or
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You
Sitey use the back of this page provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells You may P g P
drilled: construction details. You may also attach additional pages if necessary.
9.Totai well depth below land surface: �(�s SUBMITTAL INSTRUCTIONS
For multiple wells list all depths ijdierent(example-3@200'arrd 2@1001) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of easing: 40 construction to the following:
Ijwarer level is above casing,use'•+,, (ft.) Division of Water Resources,'Information Processing Unit,
11.Borehole diameter: 6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
(In.) 24b.For Injection 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,etc.) Construction to the following:
FOR WATER SUPPL WELLS ONLY Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,;Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:�11/2
Air Flaw
24c.For Water SuoDly&Injection Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs fibs the addresses) above, also submit one copy of this form within 30 days of
Amount. 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
1 Revised 2-22-2016