GW1--08062_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague
;1'4 WATERZONES : .. :: -
Well Contractor Name FROM TO i DESCRIPTION
2857-A
wsdff• 4��t.1 IS 0ft 2 4a ft l a7 Lp I'�t
NC Well Contractor Certification Number
, G,p
B&K Well Drilling Inc .15•OUTERCASING(for;multi-cased vells);URli1NER'[ifap icable} .,
FROM TO f !DIAMETER THICKNESS MATERIAL
Company Name U h t 61/8 1° SDR-21 PVC
())...3
a Q�� ..16:iINNER•CAS ORTIIBlNG'(geotheraialclosed-laop}: . ;
2.Well Construction Permit# FROM TO • DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance.etc.) ft. ft..! in.
3.Well Use(check well use): ft- ft.i in. •
Water Supply Well: 17:SCREEN
A CUlillrdl FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EtResidential•Water Supply(single)
ft ft. in.
QIndustriallCommercial E3Residential Water Supply(shared)
`"18:GROIIT ".
Ilirrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft'
0Monitoring E3Recovery ft. ft.-
Injection Well:
0Aquifcr Recharge ft. ft
�Groundwatcr Rcmcdiation
Aquifer Storage and Recovery Salinity Barrier -19:•SAND/GRAVELPACK{ a ) :, ; :
(ifTERIAL
FROM TO ' MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft..
E3Experimental Technology E3Subsidence Control ft. ft.'
Geothermal(Closed Loop) OTracer
20:.DR1I:1:1NG`LQG;(attarih.addthotia4 cessary)- r(JJ/
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DISCRIPi ION(color,herein oiVtocl type,g sin size etc.)
i y ft. 0FL r \ 7JJ777�
4.Date Wells)Completed:i i 1 .? Well ID# C 1 T�©/?
Pc ft.
t abSftI C 1, s� /qr,•�
5a.Well Location: ";;��tt (a Jt- rI�,
�1 r1 �: L `�.5� 1/U S�-u.n b
Facility/Owner e,t. y
�O� J -{t i J- -. A` Lis/ �)
Facility ID#(if applicable) ft.
3$C 3 .4k,r(1 tb•t.',/ Di 1/ (i-C _ ft. ft.;
Physical Address,City,and Zip ft. ft.• .t L. f a` �— `,t
c.r,, -c,, b c . 4 tam,Elsa oft :2CREMARE :
County Parcel Identification No.(PIN) .� v 1 UC j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ilford.?.✓'_^.n?.-.r,^ •wi/as O!a.r
(if well field,one Iat/long is sufficient) r�,
22.C illy 'on: t,�YVC:130
N W
.7--
• 6.Is(are)the well(s) Permanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certifp 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/5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information a. 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. i
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,onlyAl is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
t-�O� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:, J (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 1@/00)
construction to the following:
10.Static water level below top of casing:40• ft.
If water level is above casing,use"+ ( ) Division of Water Resources,Information Processing Unit,
1/86 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:
•
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground.Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&injection Wells: In addition to sending the form to
Chloe 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. II
Form GW-1 '
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016