GW1--04281_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 1 14.WATER ZONES
FROM TO DPSCRIPTIoN
Well Connector Name
L
2857-A
NC Well Contractor Certification Number 15.OUTER CASING for muld-cased r n OR LINER !e
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
p (L fL 6118 In' SDR-21 PVC
Company Name 15.RINER C OR TUBING eather"Cloud
2.Well Construction Permit#: FROM 1 TO I DIAMETER THTCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counry.State. Variance,err.) I ft, ft. ' in•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNE.S,S MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating(Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EhIPL.4CEMENT METHOD&AMOUNT
Non-Water Supply Well: fL M
Monitoring 13 Recovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge []Groundwater Rcmcdiation
19.SAND/GRAVEL PACK a ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft- ft.
Geothermal(Closed loop) Tracer 20.DRILLING LOG attach additional ebeeu if
FROM TO DESCRIPT1oN ess.(color,hardn 'VMck a In Sim etc)
Geothermal Heatin Coolin Return) Other(explain under>#21 Remarks) ft
4.Date Well(s)Completed — �Well ID# ft'
e`Sa.Well Location: IL t'-SL /
J '�'•L�(,.+e�� l�� tam Ll.r\ ft
Facility/Owner Name Facility lDx(ifapplicabic) fL ft.
fU (� r ft. ft. !
Physical Address,City,and Zip ft. ft.
)6'
21.REMARKS
County Parcel Identification No-(PIN) ^r t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ---
(if well field one lat/long is sufficient) 22.Certiftc ' w
N W
6.Is(are)the well(s)oPermanent or Temporary Signs c of Certified Wc11 Conga Date
��..��tl By signing this form.I hereby certify that the wrll(s)w•as(were)constrvcied in accordance
7.Is this a repair to an existing well: []Yes or K�No Kith 13A NC9C 03C.0/00 or ISA.N'CAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatio n lesplain 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,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: 4 SUBMITTAL INSTRUCTIONS
9.Total well deptl Clow land surface: O (fL) 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@ 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 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: 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) Method of test: Air Flow 24c. For Water Suppav& Iniection Wells: In addition to sending the form to
Chlor Tabs 1 1i2 Lbs the address(es) above, also submit one copy of this form within 30 Bays of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 'Forth Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016