GW1--03119_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD GW_1 orn '
For internal Use Only:
1-Well Contractor Information:
Robert Teague
Well Contractor Name ls_WATgit- JggS
28.57-/1 FROM TO DESCRIPTION_.. . >� r'.':•'.Z ':'
NC Well Contractor Certification Number r
111111111 ft
B& K Well Drilling Inc111111111111111111111
IS OUTEKCIISIIri&;r%ymm cared FROM TO DIAMETER A ,a .
t
Company Name `/ "� ��" ,-F �'
THICKNESS MATERIAL
0 ft' i D ft 6 1/8 in. SDR-21 PVC
2•Well Construction Permit#: 1 ' ,�
List al/applicable well construction permits(i.e. UIC,County,State.Variance,etc.) © TO DIAMETER .THICKNESS Ems..- `;.
THICKNESS MATERIAL
ft in
3.Well Use(check well use):
Water Supply Well:
ft. • ''
l�Agricultural �`•� FROM To �b - :m y.,- ;:
LJM�otPa�ubI1C DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
■Geothe .1(Heating/Cooling Supply) _--
Residential Water Supply(single)
MU
IndustriaUt ommercial
!..,7Residential Water Su l ft in.
- • pp y(shazed)
ration
Supply Well: most TO MATERIAL EMPLACEMENT METHOD&AMOUNT
� "'toting gg--�� Mill ft —
Injection Well: i_3Recovery
ft. ft.
I
Aquifer Recharge Groundwater Remediation ft ft —
A Aquifer Storage and Recovery E3 Salinity Barrier
FROM TO MATERIAL
1'9` 14YPACiK'd
Aquifer Teste �<� '`
OStormwater Drainage ft. ft
EMPLACEMENT METHOD
$Experimental Technology °Subsidence Control
ft
•Geothermal(Closed Loop) 0Tracer ft
at Geothermal(Heatin•Coolin•Return) FROM 2I,IMG OG • ' =,s TO DESCRIPTION-• 1 -, ,r;
�'Other(ex.lain under#21 Remarks) FROM color,bol
t ear.,soil/rocke,:rain size,etc.
ft. 1I � ft
4.Date Well(s)Completed:3' Well ID#
InningaIMPOweamsnawnrammi
5a.Well Location: C
J�L1� 11 \Y 1\ J ft
` —
•
Factlity/Owner Name j A
� � '� �, j^ l (� FaahrylD#(ifapplicable) ft ft
—LaL`e I{)l li h lr C 11 Yf �Y ��1Q� ft ft• iV t 2 2
Physical Address,City,and Zip b r r �O
:.21.REMAkKg ; e ,,iin';yf~y -r
.: x...^
County
Parcel Identification No.(piN) Inla t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: � t -
(if well field,one lat/long is sufficient) ,
22.Certifi a' n
N W 1 (
6.Is(are)the well(s)Opel•rnanent or Temporary s .W�ofCertified Well t atftfactor ���
Date
7.Is this a repair to an existing well: QYes orBy signing this form,/hereby cert •that the well(s) was(were)constructed in accordance
If this is a repair,fill out known well construction information and oain the nature al.the
cowtth 15,4 py of this�ecord2C hasObeen provided to thew'el o2C 00 Well Construction Standards and that a
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-1 is needed. Indicate TOTAL NUMBER of wells drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: SUBMITTAL.INSTRUCTIONS
For multiple wells list all depths if different(example-3@200'an 2@/00') _(ft) cons For A II Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:40 construction to the following:
(ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use'+"
11.Borehole diameter:
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.) 24b. For Iniection 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:
i i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ( Method of test: Air Flow
24c.For Water Supply&lnlee on Wells: In addition to sending the form to
Chloe Tabs 136.Disinfection type: 1/2lbs the address(es) above, also submit one copy of this form within 30 days of
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