GW1--03085_Well Construction - GW1_20240522

Form '
WELL CONSTRUCTION RECORD (GW-1). For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14wA'TER: Ol . 1. I
Well Contractor Name FROM TO D CRIPTION
2857-A �'SCie* Z'� ttr,l' s
ft. ft.
NC Well Contractor Certification Number 15.OUIERCASING--(formaltF-casedwef s)'Olrt `(Wiramt'.l,,ib _
B& K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
a ft' I Ll5 61/8 ins• SDR-21 PVC
Company Name
t, 16::: INERCASFNG OR TUB/NG t el q , ; � : :
2.Well Construction Permit#:a•_I 0141 C ^Q 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.
17 EN.-: �a.:::.... .. . ._ .... n ? �.,, %-s "-c',
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft in. -
()Industrial/Commercial DResidential Water Supply(shared)
-.18.'G'ROII'1`. .. ` ;-s' 4 r xzap;;;x �s`......<fi ^�"'.,^
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ff-
['Monitoring Recovery ft. ft.
Injection Well: ft. ft
()Aquifer Recharge ['Groundwater Remediation
19.SAND/GRAVELFACK:(tf2 ble) .. z .nt. ; ' ,.- : _
()Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
©Aquifer Test DStormwater Drainage ft. ft.
©Experimental Technology ['Subsidence Control ft. ft.
QGeothermal(Closed Loop) OTracer ZtLDRILUING'I,OG(attacliadditsoaalslfab „M. `'- a..
Geothermal(Heating/Cooling Return) (explain ) FROMO TO DESCRIPTION(color,hardness loivrock type,grain size,etc.)
( gf g [Other ex lain under#21 Remarks ,Ll� l`/\t // G t^�d1w`
1`1 ` 1� ft. t Y�
4.Date Well(s)Complete 1 S -a tile,..B. )(.NSft• �,-sTt- j /e,G !y ra,-�
5a.Well Location: 0---ft- 3 OS-Tt yy - S p.hJ ' /fit
ra d rl 1,0 \1viert e r a 6 S' G a t- S lleuec) C2/,
acility/Owner Name Facil1 i (if applicable) ft ft.
J 5 V- V.. ...e'.\. D ft. ft.
Physical Address,City,and Zip ft. ft
z1.:R£Ia1nItK5. ,. :;,:. _ .:, _. _ MAY�} d 2 °. � . �.'�:
County Parcel Identification No.(PIN) MAY 2 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ir/,`L:':'% . .° ;r•.:. a ''.v.
(if well field,one let/long is sufficient) 22.Certificatio rtW `9h"
N W 1•)1 l 5 ��L
6.Is(are)the well(s)0Permanent or Temporary Signature f Ccrttfic Well Con cto��/ Date
By signing this form, I hereby certib,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information d plain 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:
3.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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: .Q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@ 0 2@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,use"+" 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
I13a.Yield(gpm) Method of test: Air Flow 24c. For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016