GW1--08108_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: y l$tl�t_!
1.Well Contractor Information:
Robert Teague
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14:WATERZONES 1
Well Contractor Name FROM TO I DESCRIPTION '
2857-A /.2 dt' /2 dt'; l dcjJ G�`
ft. ft.4
NC Well Contractor Certification Number
B&K Well Drilling Inc ,a5:OUTERCASLNG(for:multtcased,wetls):OR i1NER ifitp liesble} •
FROM TO .. ... .:":
TO ; ,DIAMETER THICKNESS MATERIAL
Company Name 0 fL ft. 6 1/8 1° SDR-21 PVC
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i, W N 6 c a IS.`INNER CASING OR TUBING'(geotkertnal cl ICK E S >'.2.Well Construction Permit#: 'E/ e FROM TOS
DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC, way,State.Variance,etc.) ft. ft.. in.
3.Well Use(check well use): ft. ft. in.
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Water Supply Well: :17;SCREEN
aAgriCUltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Municipal/public ft. ft. in.
°Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single)
ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) :
11 I$.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery
Injection Well: ft. ft.
uifcr Recharge ft. ft.
A
q g DGroundwatcr Rcmcdiation
Aquifer Storage and Recovery Salinity Barrier .19:SANDIGRAVEL PACK,(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
°Experimental Technology DSubsidence Control ft. ft.;
OGeothermal(Closed Loop) 0 Tracer 20:DRILLING LOG"(attacliaddifionsfsheets if ue _ _
°Geothermal(Heating/Cooling Return) ) '
Other(explain under#21 Remarks)
FROM T DESCRIPTION(color,h7oWract)pe,grain size,etc.)
4.Date Wells)Completed:1 1 —2-p'��%ell 1D# V ft' --�� ''--[., r/ 'l -
5a.Well Location: -" / �/ Sr�n���ft.!
S� \CVIN'Ne.,S ( N .• ft. ft.
Facility/Owner Name Facility ID#(if licable) ft. ft.: 'k';,a,.,i,., i.,..: '\ J K.=.., .
1
/5Yr.h t Nel VV\..\ .-k 26-i
Physical Address,Citt and Zip ft. ft.
LA I. G p 1Rk t.Y . ,21 RE1VIARti'S i In ict _.:. �-,,� ... ,.3r11'I•�;
°v C:21,�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certifica' ------- 1
N W . 11—aCZ-
6.Is(are)the well(s) Permanent or Temporary Ig's nature of Certified Well Contra or��"�"} Date
By signing[has form,I hereby cer/ilj that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 1SA NCAC 02C.0100 or ISA.NCAC.02C.0200;Yell Construction Standards and that a
If this is a repair,fill out known well construction information a d e lain 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-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: a 0
For multiple wells list all depths if different(example-3@200'and 2@I00') (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40.
If water level is above casing,use"+ (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
(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 df completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) `lO Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 l�s 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. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
IRevised 2-22-2016
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