GW1--01870_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW_I) For Ir.> t 0 :_
Internal Use Only:
• 1.Well Contractor Information: I
i
Robert Teague
14 WATER'ZtilIVES: is
Well Contractor Name FROM TO DESCRIPTION ,,."fir., Y'�µ
2857-A . 7'z)ft• 7 73ft v 6, / .
J L��
NC Well Contractor Certification Number ft. ft.
B&K Well Drillin Incr15OUTERtCASING{formaltkasidtie.140RLYNER(ifs`Ifitibli a ,,W4./
g FROM TO DIAMETER THICKNESS, MATERIAL
Company Name 0 ft' I/04 fit 61/8; in• SDR-21
PVC
5.Z.Well Construction Permit#: 1S iNNERCASIPiG:.ORTUB AMETeotberuial�c[m K E SS
FROM TO ..:....._,.......�.:_.
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) DIAMETER THICKNESS MATERIAL
ft. ft. • in.
3.Well Use(check well use): ft. ft. ! in.
Water Supply Well: q7 EEN
i. ;•<. ..,s;;: .1,W.;- ::;1s t
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) elltesidential Water Supply(single)
Industrial/Commercial ft ft. in.
Residential Water Supply(shared) ,
Irrigation
• 18:=GRUU>"
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
Monitoring Recovery
•
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation ft. ft.
Aquifer Storage and Recovery .29 SAND/GRAVEITPACKtft€applicable) :_; . ;EiSalinity BarrierFROM TO MATERIAL EMPLACEMENTM ,O,... "i
METHD•
Aquifer Test
oStorrrtwater Drainage ft, R.
Experimental Technology EiSubsidence Control
ft ft.
Geothermal(Closed Loop) OTracer
:ZDi EIT3:ING:LOG:(atfachaddrnonstsheets:i£ae
Geothermal(Heating/CoolingReturn)" r
^11 �1 1 Return) (explain under#21 Remarks) brut it.
t Tom /ft (.R on(color.ham/pesss.so rock type,grain size,etc.)
4.Date Well(s)Com leted.j+•d.1- ��J /_
P I Well ID# i�, ft. 3� ft. LL 11
Sa Well Location: f4 s ff7 G fi G`t-
diG� /`'�`� f t t� •s
acility/Owner Name Facility ID#(if app licable) (B ft i ft. .14
r 1
/ 2s-ti y S L' .Ol v ft ft.
Physical Address,City,and Zip "t ft. ft 7 L:�i'• ,�a'.f�
C u l a (AG ` C 21:REMARKS r;*, �..t S.� i0.f d
County Parcel Identification No.(PIN) NfHK 2 2 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longissufficient) i11iv:G :S�'on: GIs i(( „^"^! �'
22.Certif °
!J' 7
N .W
6.Is(are)the well(s)OPermanent or Temporary of Certified Well Cotufactor Date
By signing this form./hereby cert(5 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes orr. o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information ad plain the nature of the copy of this record lies 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS;
9.Total well de below land surface:
For multiple wells list all depths tfd�erent(example-3@200'and 2@100) at) 24a. For MI Wells: Submit this form within 30 days of completion of well
construction to the following: a
10.Static water level below top of casing:40
If water level is above casing,use"+ (ft.) Division of Water Resources,Information Processing Unit,
6 ,��$ 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) B OC) Method of test: Air Flow 24c.For Water Supply S.Infection 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 t I the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Rcsoarcesf
Revised 2-22-2016
1 '