GW1--08049_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: L.., p.1 11.Well Contractor Information:
1
Robert Teague t
:i14iWATERZONF.S 'i a � _..
Well Contractor Name FROM TO ! DESCRIPTION
2857-A /1'. t./Gj 3 ft? 3n, t�ph/)
ft. ft!
NC Well Contractor Certification Number
'IS OUfER'CASING.(for multi cased•wens).OR'L1NER`(ifap flc ble);.:: '.;e
B&K Well Drilling Inc FROM TO I, 'DIAMETER THICKNESS 1 MATERIAL
Company Name 0 ft- 3.__s-fti 61/8 to SDR-21 PVC
I&INNER CASING OR TUBING(geothermal:closed400p} < .;_._:,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance.etc.) ft. ft.j in.
3.Well Use(check well use): ft. ft.1 in. .
Water Supply Well: 17.SCRFEh ;
A Cllltulal FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
t °Municipal/Public ft. ft. ' in.
°Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) IL ft. ' in.
°Industrial/Commercial °Residential Water Supply(shared)
("Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - ft. fL
Monitoring °Recovery ft. ft.
Injection Well:
ft. • ft.A ufer Recharge °Groundwater Rcmcdiation ,
Ell 19,•SANo/GRAVEL`PACR ifa •... .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL1e) EMPLACEMENT METHOD
Aquifer Test °StormwaterDrainage ft. ft.
Experimental Technology °Subsidence Control ft. ft. •
°Geothermal(Closed Loop) Tracer
20t.DRILLING f.OG(atfaeh ailditionaCstieets dhecessary}' ,
°Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTIONirlt (color,ha�pes5 soil/ ck type grain size,etc.)
Oft. 2) Sf _\t, i �
4.Date Well(s)Completed U-23 -23 Well 1D# 5 f� ft.6 jn-1 f e) s 4
t.
�
Ste. ',cc:: /l 7Well Location:
o : .J C.4'f'ls ft. ft.
V e
Facility/OwtforName Facility lDf(if applicable) ft. ft.
l.rl3 1 L i(� l..vs Ln c,., ; r ft. ft. .z, .,."¢.,._ ::..t .I`- i .,
Physical Address,City,and Zip ft. ft. •
C�, �J e.1 21.tREMARKS; _ D t; rs..'2 p 13 ...-.
County Parcel Identification No.(PIN) <-....,.,e; o t,,a,
lctw..,. ... 1[ CJ :y7�.zw
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I ,,,,tcig
(if well field,one lat/long is sufficient) 22.Certift�
N W -2 2
�l /e -33-��'
6.Is(are)the well(s)JPermanent or °Temporary Signature of Certified WclllfEractor� Date
tit By.signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or No with 15A NCAC 02C.0100 or 15A NCAC.02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information nd xplain 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:
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 fiW-I 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-3@200•and 2 a/00')
construction to the following: •
10.Static water level below top of casing:40. I •
If water level is above casing,use"+" (ft') Division of Water Resources,information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (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 form within 30 days of completion of well
(i.e.au er,ro construction to the following
g tary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3-0 Method of test: Air Flow 24c.For Water Supply&Injection 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 tbs 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