GW1--04291_Well Construction - GW1_20240719

Form
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 S aft- 3 G is ft. An
-
ft. fL
NC Well Contractor Certification Number 13.OUTER CASING for multi-cased Wells OR LINER ble
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name p fL L 61/8 1" 1 SDR.21 PVC
P Y
16.INNER CASING OR TUBING eot awA closed-1
2.Well Construction Permit#: FROM I TO I DIAMETER i THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State. variance.etc.) fL ft. in.
3.Well Use(check well use): fL ft. in.
I
ICTeothermal
er Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
othermal(Heating/Cooling Supply) Residential Water Supply(single) fL tt. in.
ustrial/Commercial Residential Water Supply(shared) IS.-GROUT
ation FROM TO MATERIAL EMPLACEMENTMETHOD&A.MOUNT
Water Supply Well: fL ft.
nitoring Recovery ft• ft.
tion Well:uifer Recharge [)Groundwater Rcmcdiation DI I ft19.SAND/GRAVEL PACK a bleuifer Storage and Recovery Salinity Bamer FROM TO MATERIAL EMPLACEMENTMETHOD
uifer Test [3Stormwater Drainage ft. ft.
perimental Technology Subsidence Control fL fLothermal(Closed Loop) Tracer 20.DRILLING LOG attach adilitiaaai sheets if Heatin Coolie Return) Other(explain under?21 Remarks) FROM ro DESCRIPTION(color,hardness soil rock a Win sta.eta)
ft. fL s-2
4.Date Well(s)Completed-5 13_Z4 Well ID#
C06-
5a.Well Location: J L fL
ft. i
Facility/OwncrNamc Facility[Drr(ifapplicablc) fL fL
lL! ft. ft,
Physical Addre City,and Zip ft. ft {
21.REMARKS '.d
ar�ciu 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutesiseconds or decimal degrees: _t a �C •
(if well field one]at/long is sufficient) 22.Certifies on:
N W
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Con for v Daw
........,,,,(((( By signing this form.1 herebv certii}-that the wells) was(were)concavcied in accordance
7.Is this a repair to an existing well: Yes or No Iiith 114 NCAC 02C.0100 or lj.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatia explain the nature of the cop of this record hac been
provided to the well owner.
repair under#21 remarks section or on the back of rfi.form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havine the same You may use the back of this page to provide additional well site details or well
construction,only I GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
3 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C. A) 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
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 pus 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 1 112 Lbs the address(es) above, aiso 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 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016