GW1--04286_Well Construction - GW1_20240719

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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 41 ft
ft. t.
NC Well Contractor Certification Number 13.OUTER CASING for multi cased wells OR LINER ff liable
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft ft. 61/8 in• SDR-21 PVC
-7 L 16.INNER CASIN OR TLBING(geothermal elused4
2.Well Construction Permit#•r1-V ! v FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State.Va once.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE THICKNE.Ci MATERIAL !
Agricultural [)Municipal/Public ft. ft. ia•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft,
Industrial/Commercial Residential Water Supply(shared) 18.CROUP
Irrigation FROM TO MATERIAL ENIPLACEMENTMETHODd ASIOCNT
Non-Water Supply Well: ft. ft.
Monitoring QRecovery ft. ft.
Injection Well:
Aquifer Recharge [3Groundwatcr Rcmcdiation19. ft. fa I
Recovery Barrier SAND/GRAVEL PACK applicable)
Aquifer Storage and Recove ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control lit. ft.
Geothermal(Closed Loop) Tracer 20.DRILLIIVG LOG attach additional sheets If necessatrYl
Geothermal(HeatingJCooling Return) FROM TO DESCRIPTION(color.hardn ittrock the.train Am atr.Other(explain under#21 Remarks) ft. IL
Al
4.Date Well(s)Completed:�'�''s Well ID# ft' ft' L
Well Location:
L fL
=5 0 n t.
Fa�cilijty/0%T.rNamc A �j Facility lD#(if applicable) ft ft
_�-t -T bar% i--= ft. ft. `-`t•-.` L , J
Physical Address.City,and Zip
21.REMARKS JUL 2024
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes:seconds or decimal degrees: /t�
(if well field,one lat/long is sufficient) 22.Certifier
N W
6.1s(are)the wells) iOPermanent or OTemporary Signature of Certified Well Contractor Date
)nd
Bi signing this form.I heretic certifi that thew 110, was(Here)constructed in accordance
7.Is this s repair to an existing well: ©Yes orNo -iih I5.4 VC.4C 02C.0100 or 15A.h'CAC 02C'.0100 Well Construction Standards and that a
If this it a repair,fill out known well construction infitrmanonplain the nature a.1 the cops of this record hoc been provided to the% ok'ner.
repair under till 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 Gay-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: // L 1 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 wet/.s list all depths ifdfi different(example-3@200'add 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 Infection Wells: In addition to sendingthe form to the address in,.4a
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 WE,�L,`LS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 5 U Method of test: Air Flow 24c. For Water Suoob'&Infection Wells: In addition to sending the form to
Chlor Tabs 1 112 Lbs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I '.worth Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016