GW1--06512_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD(GW-1 im nt Ftlrl>�
For Internal Use Only: 'i '
1.Well Contractor Information:
Robert Teague
•`14.;WATERZONES ' -• I I
Well Contractor Name FROM TO DESCRIPTION
2857-A s s,dt. sc., o ft. Zo 43
�i'�
NC Well Contractor Certification Number ft. ft.
B&K Well Drilling Inc :..1st.OUIER CASING(for multicased.wells)-ORLINER.(ffap l ble)�c:•a...,•,.;,..,
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft" 7e7 f4 61/8 rn• SDR-21 PVC
/►// /J 5 16..INNERCASING-ORTUBING;(geothermalclotedloop) ,'... .
2.Well Construction Permit#: ci — FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U!C,County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEh
•
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/public ft. ft. in.
Geothermal(Heating/Cooling Supply) Et Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remcdiation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK`(if applicable) ..
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ' ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer
20:DRILLING L;OG(atfach addr4tinal:sheets 1f o :
Geothermal(Heating/Cooling Return) r cessarY) p'
( P✓ g Other(explain under#21 Remarks) FROM TO DESCRIPTION(color. rdness,soil/rock type,grain size,etc.)
ft. '7 �• ft. J t e v.
4.Date Well(s)Completed—. (— �� Well ID# e�s ft. /`pJ3 ft.�(f r�
8a.Well Location: d�ft �� �J Z ``�`` Sv3,c �'-�
. r IL k ��-� / v,___.
ink,-G(' G rI/ v ft. ft.
Facility/Owner[�Name Facility ID#(if applicable) ft. ft
_ _
C -- .2 JT c_,�C-1 n G'C_ e) ft. • ft e' : ...::x i ve r:= .
Physical Address,City,and Zip ft. ft.
•
Glh c-c>1IAai•l i1:xEMAxKs;; : :.....Ocr1 2023 :.';.
County Parcel Identification No.(PIN) a r.• ,i. 1 ,p.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: u:"'-{;t 1
(if well field,one lat/long is sufficient) 22.Certification
W .:4777-7// — '
6.Is(are)the wells)JPermanent or (Temporary Signature ofCertifi ell Contractor Date
By signing this form.1 hereby cent fi•that the wet/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes o No with 15,4 NCAC 02C.0100 or 15.4 NGAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatio a explain the nature of the copy of this record has been provided to the well owner.
repair under 1121 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 alsoattach additional pages if necessary.
drilled: 1
,w �� SUBtMITTAL INSTRUCTIONS]
9.Total well depth below land surface: (� (ft) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200•and 2@/00')
construction to the following: I
10.Static water level below top of casing:40
If water level is above casing,use ,- (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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 m
(gP ) Method of test: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2 Ebs 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 Resource
Revised 2-22-2016