GW1--03079_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD GW_1 �' m
For internal Use Only:I.Well Contractor Information:
Robert Teague
is wa1 .
Well Contractor Name FROM TO ,,,-:g4 vi ?rc^'
DESCRIPTION -
2857-A : Zbrt 3.)/pA_
NC Well Contractor Certification Number ,�7 ft• a �\ft. 6ff 11—
B& K Well Drilling Inc Is,DUIERCasLrrG.(formttt6
FROM TO -METER. }:OI .�:S MATERIAL
ATE, RIALL" u',..
DIAMETER THICKNESS MATERIAL Company Name p ft / ft I 6 1/8 in•
SDR-21 PVC
2.Well Construction Permit#: 14'�' OR -'°"
FROM TO DIAMET. _.. 3`-iATERIA`3tk 't'.
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.) DIAMETER THICKNESS MATERIAL
fL ft in.
3.Well Use(check well use): ft
ft in.
Water Supply Well: y?.
Agricultural FROM TO .. _ r« ,:-� � `� tire:',
�MunicipaUPublic DIAMETER
SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single)
DIndustriaUCommercial ft ft. in.
Residential Water Supply(shared)
Irrigation 48RODr a * ^. r
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft
Monitoring °Recovery
Injection Well: ft. ft.
DAquifer Recharge QGroundwatcr Remediation ft ft
Aquifer Storage and Recoveryr-14 SztNDlGR Lp'A �._ .,,
�Sahnity Barrier FROM TO fi E ✓� i
Aquifer TestMATERIAL EMPLACEMENT METHOD
�Stormwater Drainage ft. ft.
°Experimental Technology Subsidence Control
ft. ft.
QGeothermal(Closed Loop) Tracer
20.DRILLING LOG(atfachaxr _■ Sd n C)Geothermal(Heatin(Heating/Cooling Return) FROM TO DESCRIPTION soil/rock
Tm
g [ Other(explain under#21 Remarks) (color,hardness,soil/rock type,gram size,etc.)
q 0 h• 1 ft dirt 6 �cr
4.Date Well(s)Completed:3'�' Well ID# 1 ft
Sa � o
Well Location: � J. ? ! 'ft curd
D tLj t r r4recttoil ft ft S .
Facility/Owner Name j.�.
Facility ID#(if applicable) ft ft L-r Q,_•r ij ; T )
a3 ID L.-u r io e Y yc� r r1ef o r c. h ft. ft. MAY
2 v 2024
ft
/
Physical Address,City,and Zip I.6 ft.
L?V R __- 777 -21. Ee. . *g
. ^° �•k9
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certificati
N W
./ 3 -Sf
6.Is(are)the well(s)f3Perntanent or ()Temporary Signs of Certified Well Co cmDate
By signing this form. l hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or with ISA 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 nd lain 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 details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
X SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D (ft)
For multiple wells list all depths ifdifferenr(example-3 200'and 2@100') t For Al 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-+ (ft.) Division of Water Resources,Information Processing Unit,
6 '+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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,
1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) 7 Method of test: Air Flow 24c.For Water Supply& Injection 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: t t/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