GW1--08110_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD GW-1 `"D'
� ) For Internal Use Only:
1.Well Contractor Information:
t.
Robert Teague 1.1'4:',WATERZONES...,...
Well Contractor Name FROM TO DESCRIPTION
2857-A / S Uft r d ft. 12
) f p•t2-%
1l "O
NC Well Contractor Certification Number .•��V,i o ft i 5ft. �//��
.:IS:OUfER'CASING(foi-:halt] *ellls):ORiEINER(if. -1{cabiey' s ...:.::-::-.:..i:
B&K Well Drilling Inc FROM TO • DIAMETER THICKNESS 1 MATERIAL '
Company Name 0 ft %S ft 61/8 in. SDR-21 PVC
I �� 1S:INNERCASINGORTUBIAMETot>IerntalfclICKloop)`7 a :.:::; "
2.Well Construction Permit#. /� 1.3- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Sta e.variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft. ft. in. i
Water Supply Well: 4'17.SCREEN
OA Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DMunicipal/Public ft ft. in.
I:1 Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single)
ft ft. m
QlndustriaUCommercial °Residential Water Supply(shared)
1S8..GROTFI ._,: ''
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring °Recovery ft. ft i
Injection Well:
A oiler Recharge ft. ft
9DGroundwatcr Rcmcdiation
r3AquiferA oiler Test and Recovery QSalinity Barrier .19.SAND/GRAVEL PACK;(ifappli able) : .. i: 1 .. -
StorageFROM TO MATERIAL EMPLACEMENT METHOD
9DStormwater Drainage ft. ft. '
°Experimental Technology DSubsidence Control ft. ft. '
OGeothermal(Closed Loop) Tracer
:20::DRILLnvcLOG(aitaertaaatnunnlslteeis.:tfaecessary)r<° .:;" F ' . .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO 'DESCRIPTION(color./�haaardnness,soil/rock type,grain sae,etc.)
rj ^ ���� ft ggfL V t r4 ` - e'�
4.Date Well(s)Completed' t P I O`3 Well ID# gft- -'ft. r I ^) SC;(4F )�Ue/
5a.Well Location: ft. ft. �'�d f-�!
a 'IklJ)N eS C's ft. ft.
Facility/Owner Name Facility iD if a licable ft ft. e - f
6 3� `Hurl P •
' ft. ft. i(+ Y,- aJ
Physical Address,City,and Zip �� ft. ft. DE 1 ZlJi)
2 1 )1 Col;lip yl :121:.REM4RKS. .If:,.7 a,' J
County Z,c;.. , ",:'D UN 1 Parcel Identification No.(PIN) D.s�,y<�.er�;�,
L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification: •
N W
6.Is(are)the well(s)0Permanent or E3Temporary Signature of Certified Well ' tractor Date
By signing this farm,I herekv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes 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 an 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
...-.1... SUBMITTAL INSTRUCTIONS
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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 ifd(fferent(example-3@200•and 2@100)
construction to the following:
10.Static water level below top of casing:40' (ft.) Division of Water'Resources,Information Processin Uni
If water level is above casing,use"+" g t,
6 ,�/$ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.. (in.) I.
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.auger,rotary,cable,direct push,etc.) construction to the followll g
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) il.D 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 I submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2 Lbs completion of well cons i ction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Di.•is:en of WaterRcsourccs Revised 2-22-2016
I ,