GW1--01841_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD •
GW-1
For Internal Use Only: 3t
1.Well Contractor Information:
Robert Teague
Well Contractor Name iAfiEgp
2857-A FROM TO w g,:s f gEti> e$ ��e Yy
DESCRIPTION .>:.
NC Well Contractor Certification Number MU G� -'+t %/
B&K Well Drilling Inc lialnliniiisna
F' b
i` -0D R''• SINGl fur..moltU
FROM TO 'Wag Y7 ,. .;Tag* i :
Company Name DIAMETER IE
0 ft
2•Well Construction Permit#: ° ® SDR 2t 12111111111
List a!1 applicable well construction permits(Ze.U/C,Coun © TO 7B 14:. EINa .v A _
ty,State,Variance,eta) © DIAMETER THICKNESS _ r '�r
IIIIIIIIII
3.Well Use(check well use):
Water Supply Well:
►� cultural E1® -
�Muidential Wale 111111111111.121111.111111111111111.11111
DIAMETERFROM TO SLOTTHICKNESS InnECIMIN
• 1� ':thermal(Heating/Cooling Supply) Residential Water Supply
Industrial/Commercial pp Y(single) Imo
°Residentia]Water Supply(shared)X Iro_ation
Non-Water Su r... ri x S£ yea ec a
Supply Well: FROM TO �...E m •°
analll
)n Monitoring g � . t�
-EMPLACEMENT METHOD&AMOUNT
Injection Well: Recovery ® �!t
E Aquifer Recharge
Groundwater Remediation T
616211
IIIIAquifer Storage and Recovery t{°Salinity Barrier ®f}�l��, C
Aquifer Test FROM afi ,,
Stormwater Drainage © EMPLACEMENT METHOD
11(ff.Experimental Technology Subsidence Control
Experi mal ental(Closed Loop)
Tracer
,�Geothermal(Heatin•Coolin•Return) ©"©
*Other(explain under#21 Remarks) € cam - Qe I
FROM ft.
TO DESCRIPTION color,hardness, `/r +�- '
O ( ess,soiVrock t.e,_ramsae.etc 4.Date Well(s)Completed: 1
�_ Well ID# 0 >. ,, -
ell Location: ft p�, f�/
a-O �' O n _
Facilliity/Owner Name S�~ < <1ft. FRIMalMAIIWAIMIIIIIIIIII
�
Facilit}7113 fapplicable) �� _
Physical Address,City,and Zip , ®®
(L _
L County
h,YEN r ly_ ?IKuFltiiano-©�„�a
pia as y z.."ru rrs3 S
Parcel Identification No.(PIN) " '
5b.Latitude and longitude in d agrees/minutes/seconds or decimal degrees:
(dwell field,one]aUlong is sufficient)
22.Certification:
N
W
6.is(are)the well(s)Opermanent or °Temporary ignaturc of Certified Well Contract
7.Is this a repair to an existing well: y� orDate
By signing this form,/hereby cert that the well(s)was(were)constructed in accordance
Ifthir is a repair,fill out known well construction informatio and ex o In the nature ofthe copy ofthis record has been provided to the well owner.
with/SA NCAC 02C.0/00 or/SA NCAC 02C.0200 Well Construction Standards and that a
repair under#2I remarks section or on the back of this form.
8.For Geoprobe/DPT or Closed-Loop 23.Site diagram or additional well details:
construction,only1 GW- P Geothermal TOT l Wells having the same You may use the back of this page to provide additional well site details or well
1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dolled: r
9.Total well depth below land surface: Z:),....0 SUBMITTAL,INSTRUCTIONS
For multiple wells list all depths ifdifferent(example-3@zoo'and 2(a)l00) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:.40 construction to the following:
/fwater level is above casing,use-4." (ft) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1/8 1617 Mail Service Center;Raleigh,NC 27699-1617
(in.)
Air Rota 24b.For Infection Wells: In additiori to sending the form to the address in;24a
12.Well construction method: Rotary above,also submit one co
auger,rotary,cable,direct push,etc.) above,al construction to the following-
(i.e. nec of this form within 30 days of completion of well
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm) 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: Air Flow 24c.For Water Su only&Infection Wells:
In
13b.Disinfection type: ____Tabs the addresses) above, also submit one copy of thisadchton to form sending within 30 form to
daysof
Amount:Chlo t 1/2 Lbs
completion of well construction to thei county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016