GW1--03411_Well Construction - GW1_20230515

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague
• '14:WATER ZONES: ,,,. i.. � -... •_ ,
Well Contractor Name FROM TO DESCRIP-1 ON
2857-A fc. ft. /'+
NC Well Contractor Certification Number ft. IS ft.
I5.OUTER CASING for malh�. sea ells:OR'LINER if a Ileable:<. .
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 3 ft' 61f8 1 in' I SDR-21 PVC
3 INNER.CASING OR TUBING:: geothermal closed lou
2.Well Construction Permit#: FROM I To I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i. .U/ ,County,Slate,Variance,etc.) ft- ft, in.
3.Well Use(check well use): f[. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSiZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply 1 (shared)
d8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT51ETHOD&AMOUNT
Non-Water Supply Well: ft. fL
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge E)Groundwatcr Remediation ft. ft.
19.SANDIGRAVELRACK'da cable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additi6nal3heets if neces
Geothermal(Heating/Cooling Return) LJOther(explain under#21 Remarks) 1
FROM TO DESCRIPTION(color,harcloo5s.soillrock h e rain size,etc.)
ft. �3 fr. �
4.Date Well(s)Completed:l. - -a Well ID# {; ft. It.
5a.Well Location fL It- Cr
ft -ft.
Facility/Owncr Name Facility ID#(if applicable) ft. ft 2 k
1-c6hc' ) R
P ical Address,City,and Zip ft. ft.
. /
I 21.REM v4RKS 4 .;
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one 120ong is sufficient) 22.Ce .r
W
6.Is(are)the well(s)oPermanent or Temporary i ture ofCcrtificd Well Co ctor Date
By signing this form,I heretic cert fy that the well(T) was(were)constructed in accordance
7.Is this a repair to an existing well: Yes No with 15A NC•AC 02C.0100 or 15.4 NC,4C 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction tajnrmatianor rplain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis form.
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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: .
P SUBMITTAL INSTRUCTIONS
9•Total well de elow land surface:- ` ( )
For multiple wells lisstt all depths ifdijjerenr(example-3C200'and 2C100') ft 24a. For All Wells: Submit this form within 30 days of completion of wellconstruction to the following:
10.Static water level below to of easing:40
P g (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is shove casing.use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For Infection 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Suoaly&Infection Wells: In addition to sending the form to
Chlor Tabs 1 t/2 Lbs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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 Revised 2-22-2016