GW1--06511_Well Construction - GW1_20231013

ELL CONSTRUCTION RECORD GW-1 For
W ``Rzr'nniF6rtYt
Internal Use Only:
1.Well Contractor Information:
Robert Teague
Well Contractor Name `14.WATER ZONES I
FROM TO DESCRIPTION
2857-A /.Sd /cC ' t n
i I'I /Y\
NC Well Contractor Certification Number (� ft. 1 ft. f
B&K Well Drilling Inc 15- R:CASING(for m eas�etlsjbR LINER(ifap'Bcable)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft• h(,, ft. I 61/$ in.
r.1 /CJSSDR-21 PVC
2.Well Construction Permit#: �� a. Q�3� y 76.INNER IN OR TUBING;:(geothermalclosed-looP) ::
List all applicable well construction permits(i.e.U!G,County.State.Variance,etc.) FROM
ft. TO DIAMETER THICKNESS MATERIAL
ft. in.
3.Well Use(check well use): ft.
ft. in.
Water Supply Well: •
17.•SCREEN'
°Agricultural °Municipal/Public FROM TO DIAM1fET in. SLOTSVE THICKNESS MATERIAL(Heating/CoolingSupply) ft. ft. in.
8
PP Y) Residential Water Supply(single)
Industrial/Commercial °Residential Water Supply(shared) ft ft in
Irrigation ,-:1K�ROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well.
ft. ft.
Monitoring 0Recovery
Injection Well ft. ft.
°Aquifer Recharge °Groundwater Remcdiation ft. ft •
19:'SAND/GRAVEL PACE(if applicable)
©lAquifer Storage and Recovery °Salinity Barrier
Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
Stormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft.
Geothermal(Closed Loop) Tracer ft
20.DRILLING LOG(attach addutonatskeets if necessary).
QGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size,etc.)
ft. ft. Id 1 A yo
14....1r\
4.Date Well(s)Completed: ).S well ID# 22ft.
5a.Well Location:, ft. ��ftr V Sd`� mot'
1 �65 4/yS�L ham, --�Al c,�
L'C eS f�4Re rS ft. ft. I.
Facili vner Name
Facility ID#(if applicable) ft. ft.
� 5y/1 ft• ft. 1 St.tom,kw,+ i V S �~�^�..� n
l I 1 i
Physical,Address,City,and Zip �.a a if ,. ft. ft. OCT i hc�,1 ��] 21;;REM.4RK5 . _1 .2023
County
Parcel Identification No.(PIN) IftC;;
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LA, 74�" 1[�f
(if well field,one lat/long is sufficient)
_
22.CeW � / _
N
6.Is(are)the well(s)0permanent or Temporary Si a[urc of Certified Well Co ctor 1 , ��
Date
Yes or No By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:
If 02C this is a repair,fill out known well construction information n splain the nature n/'the copy of this record has been provided to he wello wn rYel!Construction Standards and that a
repair under#21 remarks section or on the'back of this form.
I,
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 io provide additional well site details or well
construction,only I is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: ��s SUBMITTAL INSTRUCTIONS
(f.) I'For multiple wells list all depths/Jdfferent(example-3«200'and 2@/00') 24a. For All Wells: Submit this form within 30 days of completion of well
40 construction to the following: I+
10.Static water level below top of casing: p
(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+'
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 ifotm 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,Un�dei'ground Injection Control Program,
Q� Method1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) oAir Flow t i
of test: 24c.For Water Supply&Infection,Wells: In addition to sending the form to
Chlor Tabs
13b.
Disinfection type: Amount: 1 1/z Les the address(es) above, also submit one copy of this form within 30 days of
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