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HomeMy WebLinkAboutGW1--08052_Well Construction - GW1_20231214 r' r Iti. /,�/(2 7/c 3 Print Fc 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