GW1--08052_Well Construction - GW1_20231214

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:'
1.Well Contractor Information: 1
Robert Teague .14iWATERZONEs ,r°I.
Well Contractor Name FROM TO (DESCRIPTION
2857-A So a .„2".. „t�.
.gS f
ft
ft.3ti d ft )) frL
NC Well Contractor Certification Number 1Si.OUTER•CASING.(fornittlth-cas-ed'wells)'OR lNER'(ifap'ticable)'t
B&K Well Drilling Inc FROM TO ;DIAMETER THICKNESS g MATERIAL
Company Name 0 ft• .71.6"ft. !6 1/8 tn• SDR-21 PVC
:16aINNER CASING OR TUBING(geothecmai'clhhed loop)_'c, _ ...2.Well Construction Permit#: 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. 1 in.
Water Supply Well: 17.'SCREEN . .,.!. ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
DAgricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
DlndustriaUCommercial DResidential Water Supply(shared) IS:GRo11T
"Irrigation FROM TO 'MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft. '
Injection Well: -
DAquifer Recharge DGroundwater Rcmcdiation ft. ft.
19:SAND/GRAVEL.PACK(if applicable), '.* -
DAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DStormwaterDrainage ft. ft. '
DExperimental Technology DSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer e20i'DRILLING'LOG(attach''additionalsheetsif'necessary) _ . ".>:,
� Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO 'DESCRIPTION(color•hardneess,ssod/rock type,grain size,etc.)
c O ft. ft. d ) r�r „ t
4.Date Well(s)Completed:6 v'l3'AZ Well ID# 7C ft.,-CAS ft. ai , l /2/vG `-firA 4'
5a.Well Location: /� ^17-5 L 6) ft• v'l�`JiJ� S1� 13�) '
m r rn
Facility/Owner Name Facility ID#(if applicable)•
ft. ft. ` 4.u:�L..
.a d 3 X ,r S. .C/ /2i ft. ft. DE U I 1-4. 2023
Physical Address,City,and Zip ft ft I.
r 6L1 c. l l li''.REMARKS:'= . 11 ` ,e' 37:Nr ',Wta n ''l
County Parcel Identification No.(PIN) .. _ ___
f ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif lion: —=--.._
N W 7 „0ZS :./ /b-at,'-2ti
6.Is(are)the well(s)JPermanent or DTemporary Signature of Certified Well Cont or Date
7.Is this a repair to an existing well: Dyes o By signing this form,1 hereby'certify that the walks)was(were)constructed in accordance
r No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatio n plain the nature of the copy of this record has been provided to the Weil 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You niay also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4/16 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200•and 2@100) construction to the following:
10.Static water level below to 40.
p of casin g: (ft.) Division of Wate'r Resources,information Processing Unit,
If water level is above casing,use'•+" 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
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 ' 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.
I ,
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016