GW1--06509_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES
Well Contractor Name FROM TO I DESCRI ION
2857-A ,;.._..- as I`' Z7�Cy�(esfi. //�*,'%
r:1-- ti 7.6 ft. / V ii f L ' �".NC Well Contractor Certification Number ''..- "�'`"'s"..•i''''f """ "' 6 ` v
15.OUTER CASING(for inulgased )OR LINER(if ap licable)
B &K Well Drilling Inc OCT 1 4. Z023 FROM TO 1 DIAMETER THICKNESS MATERIAL
Company Name _ lI l 1 p ft. dy� R. 6 1/8 in' SDR-21 PVC
Irv;;,;, , ,.:a Ca!, ,7✓3. :g V4 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: r.t (
'. •. •_p,•• ,r FROM TO DIAMETER THICKNESS MATERIAL
r � ft. ft. in. I
List all applicable well construction permits(i.e.U/C.C'otmry,State.Variance,etc.)
3.Well Use(check well use): ft. ft. in.
Water Supply Well: • .17.SCREEN I • '
'4FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
eothermal(Heating/Cooling Supply) EllResidential Water Supply(single) ft. ft. in.
EIndustrial/Commercial DResidential Water Supply(shared) . it GROUT ._.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. �� ft. (-4(�(,� /� �a
Monitoring Recovery ft. ft. !
' Injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Remediation
OIAquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(it-applicable) .. • '
tY FROM TO MATERIAL EMPLACEMENT METHOD_
Aquifer Test DStormwater Drainage ft. ft.
©Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additionatsheets if necessary) .. ._ : ;
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color.hard ess.soil/rock type,grain size,etc.)
( g/ gOther(explain under#21 Remarks)
ft. a 2 ft.
4.Date Well(s)Completed: 4/ -1,rL`13 Well ID# ID\ ft. :5-f,t. ha.r.` f(,� rat1''e _,
Sa.Well Location: {r 65-t GaYs f? { j S C� I Le-�
D Carr , 1 Vsd - 6 ft. ft. ih1 O-rd •M tie- T'a n -}e-�
Facility/ownerlame F ID#(if applicable) `� - ft.. f,
7V-4 ? 6 c f-r Air M RocJ ft. ft.
Physicaly Address,City,and Zip ft. ft.
L-1 h .c.4 a IA ' 21.REMARKS }}•..
9`"
County Parcel Identification No.(PIN) �j 1 1 /ci,e- -CoC,, f7A s-{ U Y-e _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:: -
6.Is(are)the well(s)0Permanent or EITemporary Signature of Certified Well Contra 7 Date
By signing this form.I hereby certi is that the trell(.tl was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with ISA NCAC 02C.0100 or 15:1 NCAC 02C'.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction inforntation i d plain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of dais,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,o ly 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. Ydu may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total w depth below land surface:
' (ft-) 24a. F'or All Wells: iSubmit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200 and 2@100't construction to the following:
10.Static water level below to of casin 40. i,
P g� (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.) I.
24b.For Injection Wells: in addition CO 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 follow-the:
(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
13a.Yield(gpm) --6-" Method of test: Air Flow 24c.For Water Supply&Injection Wells: in addition to sending the form to
the address(es) above,`also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I'