GW1--08058_Well Construction - GW1_20231215

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Robert Teague :i;14.WATER zoNES
Well Contractor Name FROM TO I I DESCRIPTION
2857-A /��It /I' a fr
3�/,£t ftl 1 -
NC Well Conhactor Certification Number U S 1 ;
1S:OUTS CASING(fo'r picas 'M
B&K Well Drilling Incwet>sroxLINEESdap"ltMATE I
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 25 ft. 61/8 in* SDR-21 PVC
7.6::INNER CASING OR TUBING(geothermal:losed=loop)- '
2.Well Construction Permit#.a 0 a3 -Li L1 1\a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.) ft. ft. in. -
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3.Well Use(check well use): ft. ft. ' in.
Water Supply Well:
FROM TO :DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipal/Public ft. ft. in.
QGeothemlal(Heating/Cooling Supply) giResidential Water Supply(single)
ft ft. in.
Dlndustrial/Commercial OResidential Water Supply(shared)
18..GROUT
hlrril anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft:
DMonitoring DRecovery ft. ft.
Injection Well:
uifer Recharge ft. ft .
A
qOGroundwatcr Rcmcdiation
Aquifer Storage and Recovery -.19sSAND/GRAVEL`PACK,(ifapplicable) . ..,
QSalinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
DGeothennal(Closed Loop) OTracer
20:!MILTING LOG attach sailthoasl sheets if•'oe( cessary)-'
DGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DrSCRIPTION(1 color.hardness.soil/rock type,grain size etc.)
Q ft. 7S ft d 1 c �i J `
4.Date Well(s)CompletedAl-$�). Well ID# .7 ft. 5 n O_.•ft.'hr',c.rJ 12i1/� /�G,h '�'4.
U5a.Well Location: 3 b S ,�6S ' )`c ) Sc 8lc e,
)-1(b t rt:.o z,�f 1 r() WGt.�in ft. ft
Facility/Owner Name Facility IDS(if applicable) ft ft.,
� M ,.) �1 ; �ft. ft.'y,i I fors 1?( the w�cr
Physical Address,City,and Zip ft ft.
ni C 1
21.RE14I4RI{S":
County Parcel Identification No.(PIN) lnI.ur>:' ',^,n
�` 3a n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v� «t*� I
(if well field,one lat long is sufficient) 22.Certifi • n:
N W 1 '
6.Is(are)the well(s)JPermanent or OTemporary Signature of Certified Well Contra r Date
By signing this form,/hereby 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 nd a 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:
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:
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'at w100)
construction to the following:
10.Static water level below top of casing: 04
.
If water level is above casing,use..+If ) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For iniection 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 SUPP' WFi.f C f]NLy: Division of Water Resources,Underground Injection Control Program,
_ 7 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm}-'y 7 _ Method of test: Air Flow 24c.For Water Supply&iInjection Wells: in addition to sending the form to
C r Tabs 1 1t2 ins the address(es) above, also, submit one copy of this form within 30 days of
13b.Disinfection ty Amount: completion of well construction to the county health department of the county
where constructed. I I
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Form GW-1 North Carolina Department of Environmental Quality-Division of Watc I Resources Revised 2-22-2016
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