GW1--03075_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD (GW-1) For . ,e
Internal Use Only:
I.Well Contractor Information:
Robert Teague
14:WATER ZONES .;, x,
Well Contractor Name FROM TO DESCRIPTION
2857-A � u./�f 3 fit. ` _
NC Well Contractor Certification Number -3_/ vL 15 aft• , f ,
15.OUTER CASING.(for moth 1 LLaseewees OR LINER(if k)
B &K Well Drilling Inc FROM TOO1 DIAMETER THICKNESS MATERIAL
Company Name 0 ft 133 ft- 6 1/8 in' SDR-21 PVC
`�'- t 16.INNER CASING OR TUBINGpy, xfr,S•?,'.s..
2.Well Construction Permit#: b FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.;SCREEN _ �.--
QAgriCllltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QMunicipal/Public ft. ft. in.
QGeothermal(Heating Cooling Supply) En Residential Water Supply(single)
13 lndu stria 1/Commerc ial ft. in.
Residential Water Supply(shared)
Irrigation 18 GR01F7
FROM TO MATERIAL r EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft If
Monitoring E3 Recovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation ft. ft
Aquifer Stoiage and Recovery Salinity Barrier 19.SAND/GRAVELPACK(fa ble)
FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test OStormwater Drainage ft. ft.
0Experimental Technology 0Subsidence Control ft. ft
OGeothermal(Closed Loop) 0Tracer 20.DRILLING LOG(st additional stiabR
OGeothermal(Heating/CoolingReturn) FROM TO DESCRIPTION(color,hardness.soil/rock -
dOther(explain under#21 Remarks) type,grain size,etc.)
4.Date Well(s)Completed4 •S �L) b ft.
t 133
3 3 ft. I Y t. �-�
Well ID# i 3. ft.?c t. L.e-,rJ,/ /
5a.Well Location: .1 l__.?
d C ti5 r 'tr5 .
rr `` Facility/Owner.N a `, 1 \ Facility ID#(if applicable) ft ft
b�c�9r\i.5 c�� `4 J `b �,1 ,5 t V"1 hs� ft. ft.
1 { r l 3A Physical ddress,City,and Zip ` ft. ft G
)Y�i. 2L.REMARKS: 1;�,r L 4G.Z4:
County Parcel Identification No.(PIN) .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient)
22.Certificatlii'�/ I
N W /
6.Is(are)the well(s)OPermanent or Temporary Si hue of Certified Well Contract Date
By signing this form, !hereby cer46 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes orVo with 15,4 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 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 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 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1, SUBMITTAL INSTRUCTIONS
9.Total well pth below land surface: t:.(6 -s- (f.)
For multiple wells list all depths if-different(example-3@200'and 1@!00') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
40
10.Static water level below top of casing:
If water level is above casing,use o (ft.) Division of Water Resources,Information Processing Unit,
6 '+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.)
24b. For Injection 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,
2 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m J Air Flow 24c. For Water Supply&Injection Wells: In addition to sending the form to
(gP ) Method of test:
Chlor Tabsthe address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2 Lbs completion of well construction to the 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