GW1--04581_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague is wnTER.ZONES ' ::
ft. ft.
Well Contractor Name FROM TO DESCRIPTION
2857-A g5s `a 0,)Gln
ft, ft,
NC Well Contractor Certification Number
15:OUTER CASING.(forinulti casedwelli)OR'LINER(dap &able) . • :
B &K Well Drilling Inc FROM TO 71 DIAMETER THICKNESS MATERIAL
0 ft 1 3? ft' 61/8 in' SDR-21 PVC
Company Name
16 INNER'CASING OR%EUBING;(Reotheiitish¢ltised=l6op) -;
2.Well Construction Permit#:p1.� IA)yqv2•- 03 5-1-2- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
-
3.Well Use(check well use): ft. ft. in.
Water Supply Well: •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural OMunicipal/Public ft, ft. in.
OGeothermal(Heating/Cooling Supply) Et Residential Water Supply(single) ft ft. in.
DIndustrial/Commercial OResidential Water Supply(shared) _-18.GROUT :
#Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
0 Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
[]Aquifer Recharge DGroundwatcr Rcmcdiation
9..SAND/GRAVEL PACK(if applicable). • <.'_
r3lAquifer Storage and Recovery ElSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStormwater Drainage ft ft.
DExperimental Technology OSubsidence Control ft. ft.
ID Geothermal(Closed Loop) 0 Tracer
20 DRll:LLNG ;OG(attach additional sheets f uecesss"
fy)'
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.etc.)
( g/ gOther(explain under#21 Remarks)
ft ft. _
1
4.Date Well(s)Completed"1 6 - Well ID# ft• ` . ft (1.1, /D)L
5a,Well Location: .-4 $k.t t]Q 5- f- �_J 4P(S of-C
Facility/Owner Name FacilitylD#(ifapplicable) ft ft
SU'r �iokrz3 1-f" ( -''t- ft, ft. w ., .. .a-'ti, .4---1 ....
Physicalic Address,City,and Zip x ft. ft n
/ice )1 VE4-� a'Y1 � /v s 215 REMARK$ l J li' . rt ,Lh LJ • ,,..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Fj` v:'��"
(if well field,one lat/long is sufficient)
22.Cer•tificatio-
N W
S .'a -;
6.Is(are)the well(s)01Permanent or inTempoiary Signature of Ccrti ed Wcl o for Date
By signing this Arm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or�o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information plain the nature of the copy of this record has been provided to'the well owner.
repair under#2l 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 G -1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well de elow land surface: l_ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different(example-3@200'and 2 cr 100') construction to the following:
10.Static water level below top of casing:40 ft.
( ) Division of Water Resources,Information Processing Unit,
If water level is above casing.use +" 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
12.Well construction method: Air Rotary above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) \l Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 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 Rcviscd 2-22-2016