GW1--06532_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1 '
'Robert Teague 14:WATER ZONES .,.. ):.i =
Well Contractor Name FROM TO DESCRIPTION
2857-A /s aft. ,C. 0 ..2) (,„;fro J.,.
2.53r ft. �65ft. !O V M
NC Well Contractor Certification Number JJ
15..OUTER CASING(foi•mul5,ciise ,wells)OR,LINER4if.lip ticible) „' ,
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. S 7 ft. 61/8 1!, , in, SDR-21 PVC
Company Name
/ .16..INNER CASING OR-TUBING(geothertiial dosed=loop)
2.Well Construction Permit#:a� - /7$f�j 1. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.Stale.Variance.etc.) ft. ft. 1' in.
i
3.Well Use(check well use): ft. ft. in.
•117.SCREEN ,, ,.
Water Supply Weil: „; ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18 GROUT. -,:r-< ,_. i ?.°
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. I1
Monitoring DRecovery ft. ft. r
Injection Well: ft. ft.
Aquifer Recharge D. Groundwater Rcmcdiation
Aquifer Storage and Recovery Salini Barrier 19;SAND/GRAVEL PACK if a "licable -.'.. -•'
@,-1' ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. li
Experimental Technology E3 Subsidence Control ft. ft. i'
Geothermal(Closed Loop) DTracer .20.DRILLING LOG(attach additioi ai'sheets if oecessiry)' , -,;-;,,.:
Geothermal(Heating/Cooling FROM TO DESCRIPTION(color.hardness,soil/rock type,grain size.etc.)
( g! g Retum) Other(explain under#21 Remarks) ft. %7ft.
4 ?....40 e_..K.
4.Date Well(s)Complete 4`(`J3 Well ID# 52 ft.g h 5ft. c � (l
d' 14_,
5a.Well Location: 0�ft. ��ft. / 47 :an-C-4
/� /G 1
0:, -f ar�-.11 ._ C. , ft. ft. h /3
Facility/Owner amc Facility iD#(if applicable) ft. ft. L. f 3 Yssi I .spr )h15 iZci hpV �1C �• f.• Lc.� G� �v� ft. ft. r l�.,
Physical Address,City,and Zip ft. ft. I •° ZnP3
'21:REMARK:4 ir;,�„'Y
County Parcel Identification No.(PIN) I' Dt1:, ,1P,• b' �litt
� n'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N
W -•Vee.---‘Fj----',/ '
' 6.Is(are)the well(s)JPermanent or EITemporary Signature of Certified Well ontractor Date
By signing this form,/hereby certi(,i'that the well(s)has(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ;',.4 No with 15.1 NCAC 02C.0!00 or I5a NCAC 02C.0200 IVell Construction Standards and that a
If this is a repair.fill out known well construction information and explain 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 this form.
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!to provide additional well site details or well
construction,only 1 GW J is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i.
3 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: G 5 (ft.
24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2 a 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
II.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: i,
construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYt
WELLS ONLY: 1636 Mail Service Cei er,Raleigh,NC 27699-1636
13a.Yield(gpm) I 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016