GW1--01847_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Fore 1'
1.Well Contractor Information:
Robert Teague
alttI ATERZOliE5, 'ajM F; -.`..k' a x k .,'j
Well Contractor Name FROMC TO/` D CRIPT}ON ,._ l
2857-A 5 q d ,Ot• ' Up gi—
ft. ft. , 1
NC Well Contractor Certification Number
B&K Well Drilling Inc 15 ov ltCSING;(nor=.minimeaseafweI OicIANW(i£8 BeibliM g.yA:
FROM T9 DIAMETER THICKNESS MATERIAL
Company Name 0 ft b 5ft 16 1/8 in' SDR-21 PVC
C ` ,�) 16.Y.Ir7NER C"ASING,Oleit ftiNa(geotliermas gIosed to:op}'eL .x : y sMr
2.Well Construction Permit#:G W L �� 7( FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft. ft. • in.
Water Supply Well: ;.17it-SCREEN.,i ' x�-._,, e x r f ,: s..c�:.z.: t ;v .°�.,;ti`<;:?
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) •
f6 ft. m
Industrial/Commercial Residential Water Supply(shared)
18.EGROUTx}. fir:;oi _r .r. ath-. ...atd cam ,.,s
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring DRecovery ft. ft.
Injection Well:
ft. ftAquifer Recharge °Groundwater Remediation
Aquifer Storage and Recoveryx94SANDIGRAVEL PACIC arapplicatiie�-<.,�. 1<c .2 t h:.., -e.tr .,,{_ s ;ti:
°Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test! DStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °g�,Tracer M,
@-.I' _>20"sllR1T,I:TNG;IOG;(aft"ac}raddrhoiiatstreets'if"ae�csa� ,f.�,z��s� iM a.RM:,yy;
Geothermal(Heating/Cooling Return) °Other(explain under#2I Remarks) FROM TO DESCRIPTION(color,lo hardness ilfrvck type,grain she.etc.)
�7 O ft. / ft. d 1•I'—�1� �1 /�p L�
4.Date Well(s)Completed:"),—.7—— 21(Well ID# C S ft.
h2 U S A cv I ci o -tI -
Sa.Well Location:
V ftu-) r/�.G�j G ,,‘ ft. ft.
Facility/Owndr Name Facility ID#(if applicable) ft. ft ,-, i
a.ttatT) V\ ' Y Y ft. ft. �. �wi' t @y ?
Physical Address,City,and Zip f ft ft MAN 2 2 2024
�
L%NN L� ti�6 V` zi:I M Ics no s:` giizr-m m.°rag ,ti r xgi7,;:=
County IfliOitT ;;� a� /g
Parcel Identification No.(PIN) 7 y ie
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
N W
�'- ?- 21/
6.Is(are)the well(s) Permanent or OTemporary ignature of Certified Well Con ctor Date
By signing this form,/hereby cent fy tlh'at the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: P') es or DNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a If this is a repair,fill out known well constructs""nformation and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the ba, o 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
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
r(',�,
t� SUBMITTAL INSTRUCTIONS
9.Total well dept ow land surface: `}V� (ft) 24a. For MI Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')
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,
, 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (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
construction to the following:(i.e.auger,rotary,cable,direct push,etc.)
1
FOR WATER SUPPLY W LLS 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
Chlor 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. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016