GW1--04483_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD (GW-11
For Internal Use Only:
1.Well Contractor Information:
Robed Teague
14:WATERZONES ."
FROM To ' DESCRIPTION
Well Contractor Name
/ CO-ft. ) o ft.
2857-A b ft `—Z p ft. .Ju :; .._:
NC Well Contractor Certification Number 15:OUTERCASING for.:in -ea5 dwells ORL/NERi1a trailEl
j'lickhle • -
FROM TO DIAMETER THICKNESS
B &K Well Drilling Inc 0 ft NM 6 1/8 r"• SDR-21 PVC
Company Name 9 16.INNER"CASINGiOR''FL)BING'.
eothermid!elosed-Ioo.'` •.
0 !- FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:�1../
ft. ft. in.
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. ft. in.
•3.Well Use(check well use):
17i,SCREEN:;;:'
KNESS
RIAL
Water Supply Well: S
FROM TO DIAMETER SLOT SIZE THIC
MATE
in.
DA cultural OMunicipal/Public ft. ft
Agr
icultural
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
Qlndusttial/Commercial OResidential Water Supply(shared) r:1S.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
IItrigation ft. ft
Non-Water Supply Well: ft. ft. —
•Monitoring Recovery
IIIIIIIIIIIIIIIIIIII
Injection Well: 1111111111111111111111
ft. ft —..
(3AquiferRecharge 0 Groundwater Rcmcdiation ;91$AND/GIU11?ELYACK'rfa•• ruble EMPLACEMENT METHOD
g-�Salinl
Aquifer Storage and Recovery t7'Barrier FROM TO ft. ft
Aquifer Test ft-
Di Drainage
Subsidence Control
ft. ft.
'pEx therm l(ClosedTechnology .. ";'
p t;,: r ':`ai atfachadditionals)ieetsafne �.:;
111111111111111111111111111111
Geothermal Loop) OTracer FROM TO DESCRIPI ION(color,hardness,sorUrock .e rain size.etc.)
, Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) milzzi
`n • _
— -
4.Date Well(s)Completed:(o� Well ID#
5a.Well Location: •
_2t),11. . IM
IP
ft. ft.
Facility/Owner Natt c Facility ID#(if applicable)
---1
ft. ft.
t c�YS )c�e- t r 1 1ve�o IIIIIIIMIWFAIIMEMIM
ft. ft. iiimmagimigliM
21s
>�
Physical Address,City,and Zip ' � '=-"REhIAItKS
f `n\ Parcel Identification No.(PIN)
County �-_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one lat/long is sufficient) ��_� D
N W •C' �
Signature of Certified We ontractor
Date
6.Is(are)the well(s)0Permanent or OTemporary
By signing this Iorm,I hereby certJY that the well(,)was(were)constructed in accordance
A
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cmutruction Standards and that a
7.
!f hs t a a repair oo kn exiw ll well: Yes ono ljthis is a repair,f(l out known well canstruction injnrntatiorsplain the nature of the
copyofthis 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
drilled:
9.Total well epth below land surface: (ft) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2©100') construction to the following:
above casing,use"+"
40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is aab
10.Static waterlevel below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6 1/8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:
Air Rotary construction to the following:
(i.e.auger,rotary,cable,direct push.etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) i the address(es) above, also submit one copy of this form within 30 days of
Chloe Tabs 1 1I2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016