GW1--03121_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD GW_1 �"`."
For Internal Use Only:
1.Well Contractor Information:
Robert Teague
Well Contractor Name 152 - A1�T '
FROM TO Y .
2857-A DEscxi• Ion
F 31-9ah
NC Well Contractor Certification Number Oft- L�g eft.
B& K Well Drilling Inc I$GU E1 GASING.fo>: �.- -
FROM TO _ r.R:r IC NESS _ .;
DIAMETER THICKNESS MATERIAL
Company Name 0 ft-
' IMIll 6 1/8 in' SIDR-21
2.Well Construction Permit#•5 W p2 3 — (� PVC
/N� 1 7 VL R e1SIAl UR $�tMETE
List all applicable well construction permits(i.e.UIC, State, EOM TO DIAMETER ` E �'
County, Partance,etc.) © ® THI� MATERIAL
ft
3.Well Use(check well use):
Water Supply Well: ft• in.
Agricultural 0MttrricipaUPublic FROM TO DIAMETER SLOT SIZE THICKNESS'xYMA1ERIALI
II Geothermal(Heating/CoolingSu 1 ft © in.
PP Y) Residential Water Supply(single)
it Industrial/Commercialft-
Mil in.
�Resideatial Water Supply(shared)
IrTi:ation It1z;ROur .,`' F. ,—
Non-Water Supply Well: FROM TO a ...
�-M'�TE—^EMPLACEMENT METHOD tic AMOUNT
ft
Monitoring DRecovery
Injection Well: ft. ft. —Aquifer Recharge
Groundwater Remediation ft. ft.
$ —
IF Aquifer Storage and Recovery Salinity Barrier 34"S t1�ID1oltA1 pgE3[? -, e E s
ji Aquifer Test FROM TO MATERIAL '' °°F
0Stormwater Drainage ft, ft EMPLACEMENT METHOD
$Experimental Technology (3Subsidence Control
ft ft$Geothermal(Closed Loop) Tracer
20.DRctLING OG?a adlifaiaa sheetrP
hilt Geothermal(Heatin• Coolin•Return) $'Other(ex.lain under#21 Remarks) FROM TO v'
C�-� DligHp!.n CRIPTION( I V, Il,P�";'
^� V ft. �-
4.Date Well(s)Completed:.3 '2 1— 1 , `� /?O >e
Well ID# Mill tat t
Sa.Well Location: a
Facility/Owner Name --C.Ji. ` w• , ��
Facility ID#(if applicable
1-1. e,r riS ►1 ,, I p ft. ft
Physical Address,City,and Zip
.a //�� I ft ft
6:20l�k/ z1,RE1t1a1iFcs.r i �► ' V. 7
County
Parcel Identification No.(PIN) M A 2J L O7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: VI I
(if well field,one lat/long is sufficient) •l�.Y
22.Certif n: 1Ti- ` . .- .,y
N W —
6.Is(are)the well(s)lapermanent or DTemporary lure of Certified Well Contra e
Date
7.Is this a repair to an existing well: ©yes or No Si signing this form,I hereby certt&that the well(s)was(were)constructed in accordance
with ofISAt NCAC 02Ch .0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
repair
If this is a repair,fill out known well construction information lain the nature of the copy this record has been provided to the well owner.
rep under#2!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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
S% SUBMITTAL INSTRUCTIONS
9.Total we epth below land surface: /
For multiple wells list all depths ifdii different(example-3@200'and 2@I00') (ft) 24a. For MI Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:
40 construction to the following:
If water level is above casing,use +" (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 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:
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&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 cos the addresses) 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
13b.Disinfection type:
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-20]6