GW1--06537_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES i i •
Well Contractor Name FROM TO DESCRIPTION
2857-A Li) ft. teSd ft. f��1 l�h•%
ft. ft 11
NC Well Contractor Certification Number
.15.OUTER CASING(for niulti cased wells)OR LINER'(if ap licable) •
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL -
Company Name p ft. f� ft. 6 t�8 in• SDR-21 PVC
,(� 16.INNER CASING OR TUBING'(geothermal closed-loop) • ' . -.
2.Well Construction Permit#: /D 7! 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: 17.SCREEN .•
DA CUIYDIaI FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMunicipaVPublic ft. ft. in.
DGeothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
ft, ft. in.
Dlndustrial/Commercial DResidential Water Supply(shared)
18.GROUT
'irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
0Monitoring D Recovery ft. ft.
Injection Well:
f. ft.Aquifer Recharge DGroundwatcr Remediation Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
ry FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test DStormwater Drainage ft. ft.
DExperimental Technology DiSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)....
QGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soil/rock type grain s ze etc.)
ft .
4.Date Weil(s)Completed: '�' Well ID# `O ft- I'5 ft
�G
5a.Well Location: 2t..15ft.t r��s fft.t. /_a j r ) . / eu
s 1-th 1 Iy�eS G, )r,, Yi J f-
Facility/OwnerName Facility ID#(if applicable) ft. ft. 1::::;:'i. ,�T..r I;i .^-.t
DI J ' WI G I-) v21 le.� wci T ,:f4 ft. 1 L,�, i
Physical Ad ss,City,and Zip C n.L�)Sft. ft. OC I 1.ii."
202C,e_ ue \ �1.71 Lj cl 21.REdIARICS ItJi (� 6 :f , r+ K:.'• t!' -.
County Parcel Identification No.(PIN) r'>t_F+•.�K,. "3. r` 1ID•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
i'
N W -2 - �-,
6.Is(are)the well(s)0Permanent or DITemporary Signature of Certified LVcll C trot Date
By signing this form.I hereby certify that the well(.sl was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or No with 154 NCAC 02C.0100 or I5.4'.NCAC 02C.0200 ii'elI Construction Standards and that a '
If this is a repair,fill out known well construction information an lain the nature gfthe copy of this record has been provided to the troll owner.
repair under#2/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 also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C200'and 2 a 100')
construction to the following:
10.Static water level below top of casing:40 ft. '
If water level is above casing,use ( ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (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,lUnderground Injection Control Program,
1636 Mail Servie (Center,Raleigh,NC 27699-1636
"""'
13a.Yield(gpm) l ���\ Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subnlit one copy of this form within 30 days of
13b.DisinfectionChlor Tabs 1 1/2 Les
type: Amount: completion of well construction to the county health department of the county
where constructed. ' I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016