GW1--04284_Well Construction - GW1_20240719

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2857-A b fL eft.
fL 3 ft.
NC Well Contractor Certification Number 13. UTER CA I.G 11vir multi OR LINER ble
B & K Well Drilling Inc FROM T DIAMETER THICKNESS MATERIAL
Company Name 0 ft ft- 1 6 1/8 in- SDR-21 PVC
�1 16.INNER CASING OR TUBING eothermai closed-loop)
2.Well Construction Permit#: 1 t> 2 lS FROM I 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): fL ft. in.
WaterSupply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public fL ft, in.
Geothermal(HeatingiCooling Supply) Residential Water Supply(single) fL ft. in,
Industrial/Commercial Residential Water Supply(shared) 18,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery
Injection Well:
:)Aquifer Recharge QGroundwatcr Rcmcdiation ft. ft.
19.SAND/GRAVEL PACK ifa ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attachadditional sheets if
FROM TO DESCRIPTI N(mlar,hardne wil_/ ck e, rain size,etc.)
Geothermal(Hearin Coolin Return) Other(explain under?f21 Remarks) ft ft. r
4.Date Weil(s)Completed: 4 L2e�a4 Well ID# ft, ft.
5a.Well Location: V ft. a �/
ft.
Facility/OwncrName Facility ID#(ifapplicaabbic) ft.
Physical Address,City,and Zip Ll I JT( ft. ft.
� � 1 21.REMARKS J
County Parcel Identification No.(PIN) ^. ,r JitTl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one)at/long is sufficient)
22.Certifi
N W
6.Is(are)the well(s)oPermanent or 01rempor ry Sienaturc of Certified Well Con or Date
By signing this farm./herebv certify that the wells) was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No with 15A NC.4C 02C.0100 or 15.4 NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known we//construction informal n an explain the nature of the copy of this record has heen prnvided 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 1 -1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wel/s list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below to of easing:40
P g� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use,.-" 1617 Nfail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b. For Iniecton 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&Iniecton 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 tbs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016