GW1--03084_Well Construction - GW1_20240522

I Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2857-A / 3( / KOft- 9� (�
NC Well Contractor Certification Number 26 et
�.7�ft /_�
15.OUTER CASLNG(for multi-cco-assseeeddd we(s)OR LINER(if a We) ,
B & K Well Drilling Inc _FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fe 5
2 ft 6 1/8 in* SDR-21 PVC
16.INNER CASING OR TUBING(geothermal elosed-loop)
2.Well Construction Permit#: FROM TO l 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural °Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft ft in.
0Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
['Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
Monitoring DRecovery ft. ft.
Injection Well: -
ft. ft.
Aquifer Recharge °Groundwater Rcmcdiation
19.SAND/GRAYEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
aExperimental Technology °Subsidence Control ft. ft-
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,ha so,U,ock e,grain size,etc)
( g/ g []Other(explain under#21 Remarks) C3 ft-S. �8 j r� / 0
4.Date Well(s)Completed:LL-L $-v eil ID# ,,, 3 ft•a�'t L�2 )L G ��yn �.
5a.Well Location: /x (/
(2re..r) 1 av ,1_A r 1) c.,0 - _
Facility/Owner Facility ID#(if applicable) _ ft ft �_„i ., _ x r 1� 1."" •
,r
1
t4 a( 7 \C i ( 0 h R e,n1 pi ft ft. /t
Physical Address,City,and Zip ft. ft. MAY 2 ,/r z r,U L't
` \ 1 ' 21.REMARKS
County 1 Parcel Identification No.(PIN) ) f5'Ci 3C'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certifl • n:
N W � 9 _ ig r`,D.,
6.Is(are)the well(s)0Permanent or °Temporary S✓i turc of Certified Well Contract° Date
By signing this form,I hereby certify that the well(s)was(were)consnveted in accordance
7.Is this a repair to an existing well Yes or ONo wide ISA NC.AC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well cons! ion i ormation 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 oft is 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well pth below land surface: 3 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C200'and 2 a)100) construction to the following:
10.Static water level below top of casing:40 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing.we"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b. For Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Li D Method of test: Air Flow 24c. For Water Supply& Injection Wells: In addition to sending the form to
Chloe Tabs 1 1Y1 tn5 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016