GW1--08060_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD GW-1 I.F.Pipit
For Internal Use Only:
1.Well Contractor Information:
Robert Teague
..,--
W 14:WATER ZONES .Well Contractor Name
I
2857-A FROM TO I DESCRIP ION
d / ft y�
NC Well Contractor Certification Oft:tonNumbcr ��� �b �+J
B&K Well Drilling Inc •15 RC SING:(for ed.w ); RL Rlifiip•fleable)
FROM �7+0 DIAMETER I THICKNESS MATERIAL
Company Name D ft..I
/p9.e 61i8 tn• SDR-21 PVC
2.Well Construction Permit# 76i:INNERCASINGORTUBING'(geotherina}c10sed-loop)'
List all applicable well construction permits(i.e.UIC.co Stale.Variance,etc.) FROM ft. TO DIAMETER THICKNESS MATERIAL
fL in.
3.Well Use(check well use): ft. ft: in.
Water Supply Well: I7.SCREEN`
If
Agricultural FROM TO
Ci1Vhtnicipal/PubIiC 'DIAMETER, SLOT SIZE THICKNESS MATERIAL
a Geothermal(Heating/Cooling Supply)I Residential Waterft. ft. 1 in.
-' { Supply(single)
*Industrial/Commercial � ft ft. in.
Residential Water Supply(shared)
•: ••tion 18.GROUT
No, Water Supply Well: FROM TO
MATERIAL EMPLACEMENT METHOD&AMOUNT
f4 ft:
NI Monitoring Recovery
Injection Well: ft. ft.
II Aquifer Recharge DGroundwatcrRcmcdiation ft. ft.
If+Aquifer Storage and Recovery • 19.'SAND/GRAVEL:PACK:(tf appp)icable)
Salinity Barrier
Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
oStormwater Drainage ft. ft. I
•Experimental Technology E3Subsidence Control
Geothermal(Closed Loop) Tracer ft ft.
20:DRILILLNG LOG:(attach'sdditioaifilii ets itnecessaty).
III Geothermal(Heating/Cooling Return) JOther(explain under#21 Remarks) FROM TO
DESCRIPTION(color,hardness,soil/rock hype,gram size,etc.)
n ft. j �ft.' .) I.r„4 1/ . ,�' i
4.Date Well(s)Completed: //f 2/1,3 Well ID# a ft ft .. /�
5a.Well Location: ` ��� ,rrJ � 1� �, i'
D alt. Ile-1 on ft.
Facility/(honer Name c -
Facility ID#(ifapplicable) ft ft. 4e , r s {
C1LMMI i-k vx. .%-- , No-WY-6 n ft. ft-.
Physical Address,City,and Zip ft ft. DEC , 2023 j
l}-ACQ.(1)1 A 21:REMAR S •:'. ii-r ,, :� !1•t!,-
h_,
County Parcel Identification No.(PIN) Bb;�``SJ e;F
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certificatiomr
N W �(...i vl '�6.Is(are)the wells) Permanent or Temporary Signature of Certified Wcll Con ctor - i t/Z`Z 3
Date
Yes or NoBy signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:
If this is a repair,fill out known well construction information nd plain the nature of the copy of'th with 15,4
��ecord has b AC 02C �n provided to the Ke/I ow 0 rWe1f Construction Standards and that a
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 needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
. drilled:
jCe SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �-�—e
(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'and 2@i0 •)
construction to the following:
40
10.Static water level below top of casing: . (ft.)If water level is above casing,use-+ Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
(
11.Borehole diameter: (in.) 24b. For Infection 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 following:
I'
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
//�� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,6 Method of test: Air Flow 24c.For Water Supply&
¢r, Injection Wells: In addition to sending the form to
13b.Disinfection type:✓Chlor Tabs Amount: ?1iz Lbs the address(es) above, also ;submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
1
Form GW-I
North Carolina Department of Environmental Quality-Division of Water Rcsourc�s •
� Revised 2-22-2016
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