GW1--04287_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 Vf O ft L d fr.
2
NC Well Contractor Certification Number 15.OUTER CASING for mul vas OR LINER ff able
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' ' ft. 61/8 in' I SDR-21 PVC
b,�Q�' \ 16.INNER CASING OR TUBING eothermal dosed4
2.Well Construction Permit#: 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State. Variance,etc.) fL ft. in.
3.Well Use(check well use): fc. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft.
Geothermal(Heating/Cooling 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. fL
Monitoring Recovery
Injection Well:
Aquifer Recharge IDGroundwatcr Rcmediation ft. ft.
19.SAND/GRAVEL PACK applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if
E,SCRI PITO
Geothermal Hearin Coolin FROM TO N(-Ior,ha wilt,ock type,gnin size•etc.)Return) Other(explain under Remarks) ft L
4.Date Well(s)Completed_ Well ID# ft (�
5a.Well Location: `' fL fL
I N`so
y` fL ft-
t \ sue.
Facility/OwncrName cilityiD#(ifapplicabl fL ft l ` t-•
3 ft.
//Physical ddrcss,Cily,and Zip ft. ft.
21.REMARKS 4:
County Parcel Identification No.(PIN) a�' �J�C'`y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification: —1
6.Is(are)the well(s)oPermanent or 13Temporary c of Certified Well Contra or Date
Bc signing this form, i hereby certify'that the well(s) was(were)constructed in accordance
7.is this a repair to an existing well: es or "No dill 1SA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constrXkqffhisform.
rmation and explain the nature ajthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the
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 -I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
^ SUBMITTAL INSTRUCTIONS
9.Total well d below land surface: d� (I-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100') construction to the following:
10.Static water level below to of casing: 40
P g� (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
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&lniection 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 Lbs 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 Watcr Resources Revised 2-22-2016