GW1--03581_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD
I.Well Contractor Information: For Internal Use Only:
Robert Teague
: ER ZON ES
We11 Contractor Name 14WAT "
FROM TO DESCRIPTION
2857-A 5o ft. 16a ft.
NC Well Contractor Certification Number 3 ft b ft_
B &K Well Drilling Inc 15.:OUTERCASING::ormiddi asedwells )R'LMR ffa"'Iicable
FROM TO DIAMETER THICKNESS MATER[AL
Company Name 0 fL R 6 1/8 in. SOR-21 PVC
l, _�� 16:IlYNER'.-e1S1NG;OR1fIBIN.G tlteraiAlclostd=1'2.Well Construction Permit#: ^ V 77 i[torvt
List all applicable well construction permits(t.e.UISlate, ari�e,etc.) ft. TO ft. DIAMETER in.
THICKNESS MATERIAL
3.Well Use(check well use): fc, ft. in.
Water SnPP1Y.Well: 17:.SCREEN;:.:°. :.... _...
Agricultural FROM TO DIA sIETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial ft ft. in.
�Residenrial Water Supply(shared)
1$,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&4MUUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery
Injection Well: ft• ft.
Aquifer Recharge DGroundwater Remcdiation ft. ft
Aquifer Storage and Recovery Salinity Barrier 19.SANDIGRAVEL.PACK da cattle
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ostotmwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRIB LNG LOG:attach addifiaiisl sheefsh iieces
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) FROM TO FSCRIP N(color•hardn soil/rock tv e,'grain size,ja etc.)
Well ID# ft. ft.
4.Date Well(s)Completed_ W
Sp�a.Well Location: ft, ft.
ft. ft.
L/r� F
Faacility/Owner Name / A( Facility ID#(if applicable) ft. ft t` g
'7-/U-��f' V'I L,J`I ft ft. �5f f
Physical Address,City,and Zip fL 8. I I
2LREMARKS..
County Parcel Identification No.'(PIN)— In ,ii?ra.•MA
Y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat(long is sufficient)
22.Certification:
N `,l,
6.Is(are)the well(s)OPermanent or Temporary Si_nat.ofCcrtificd C ntractor Date
,�y signing this firm./herehv certyJ Mal the wells)xas(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ND with 1S.4 NC.4C 02C.0100 or 15.4 NCAC 02C.0100 Well Construction Standards and that a
lj[his is a repair,fill out known well construction infr�rmation a"nnd"'"'"earplain the nature ojthe Copy ajthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth elow land surface: x (ft)
For multiple wells list all depths ifdlfjerent(example-3@200'and 1«100') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40 (ft)/fwater level is above casing,use Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (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 SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)S6 . ow .Air Flow ``
Method of test. 24c.For Water Supply&lnjecton Wells: In addition to sending the form to
13b.Disinfection e: Chlor Tabs the address(es) above• also submit one
copy of this form within 30 days of
1 1/2 Ibs
type: Amount: COMDletion of well construction to the county health.department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Q Division of Water Resources I Revised 2-22-2016