GW1--00460_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: .
Robert Teague x4:WATER:ZONES'.,'.{
Well Con ctor Name FROM TO I DESCRIPTION
2857 A. $5111ft 3 r . 1 0 Z ,
Vft. Tftft. 1
NC Well Contractor Certification Number
GIS:UUI'ER'CASING(fofi multl�cased wells)OR iLINER(Tap licagle..- ,�
B&K Well Drilling Inc FROM TO I DIAMETER THICKNESS MATERIAL
0 ft. ft.! 61/8 m SDR-21 PVC
Company Name C,
�� l� ! Ifi:IN1 ERCASINGORTUBINMETEREherma}eSICKNb0)3j a.ER ,
2.Well Construction Permit 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/ County,State.Variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft. ft.; in.
Water Supply Well': 17..SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural DMunicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) EDResidential Water Supply(single) ft ft. in.
DIndustrial/Commercial DResidential Water Supply(shared)
IlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
CDMonitoring DRecovery ft. ft.'
Injection Well:
ft. ft.
()Aquifer Recharge DGroundwatcr Rcmcdiation
.:19:SANDtGRAVEL:PACK(ifapplicable) . .` ; -''
DAquifer Storage and Recovery Salinity Barrier FROM TO . MATERIAL EMPLACEMENT METHOD
DAquifer Test DStormwater Drainage ft. ft.
DExperimental Technology DISubsidence Control ft ft.
Geothermal(Closed Loop) OTracer 201DRILLINGLOG(atfachadditiocaLsheetsifnerkisny)" ,.
FROM TO DESCRIPTION(col ,hardness.soil/reek type,grain size,etc.)
Geothermal(Heating/Cooling Return)ur Other(explain under 01 Remarks) ft. C( ft i r� f a �, )„
4.Date Well(s)Completed: Z L-.� Bell ID# (��� t rt /C
ft 34.5 .i }.� Ylt
Sa.Wel Location: .�� bisCLI�
?C/'�"t C s � ! CK ft. ft.1
Facility/Owner Name {/� .,r Facility ID#/(if applicable) '
/fi r( �rV/ V r t, }ij ft. ft. a it„ *+.
Physical Address,City,and Zip ft ft er g"e' t
��n �t(� ,I/,'N n
v '�� +� 6 21:RE1�14RIC$ • ?G °
County Parcel Identification No.(PIN) 1Rj Y ....4 a a 7-;,‘,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: : ` Obi -e'O' '
(if well field,one lat/long is sufficient) 22.Certification:
N W �J /i2 eGLU
6.Is(are)the well(s)OPermanent or Temporary 'gm urc of Cc cd We Contractor Dare
rrite2ii- 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 with/SA NCAC 02C-0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and ex ain the nature of-the copyof this record ha 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_Si7V-1 is needed. Indicate TOTAL NUMBER of wells construction details. You,may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l 0 S (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 2C100') construction to the following:
10.Static water level below top of casing:40' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail'Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 b'() Method of test: Air Flow 24c.For Water SunDly&'Iniection Wells: In addition to sending the form to
Chlor Tabs the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: '1/2 Us completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality.Division of Water Resources Revised 2-22-2016