GW1--05490_Well Construction - GW1_20240912

rrrn€1 ae :_
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
I
Robert Teague 14.WATER ZONES • I 1 •
Well Contractor Name •
FROM TO DESCRIPTION
2857-A 1d[ft. 129 ft. //4114^-)
NC Well Contractor Certification Number
515' 645 " It(ll r.
15.OUTER CASING(for multi wells)OR LINER(ff a ticable)
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft.
q� ft. 61/81' ! in' SDR-21 PVC
2)40.10 3 -Q -16.INNER CASING OR TUBING(geothermal closed-loop) . '• . ' -
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State.Variance.etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
ta Agricultural unicipal/Public ft. ft. fin.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Dlndusuial/Commercial DResidential Water Supply(shared) 1S.GROUT ::
I !Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring 0Recovery ft. ft. .
I.... ,r."r...,..
Injection Well:
Aquifer Rechar cft. ft. 6 .`' L t
9 g ,0Groundwatcr Rcmcdiation ,''� , , ,� i..i
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(if applicable) r�
tY FROM TO MATERIAL EMPCATEMENTT IEMI`Il
DAquifer Test InStormwater Drainageft. ft. `Tl
L-R_..
OExperimental Technology Et Subsidence Control ft. ft. '"''1"°'",,,.. `rr"Ni5`;?w Ufeg
rdc.r>a a'
DGeothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) , ,•'`°"�'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness soil/rock type grain size.etc.)
/7 0 ft. $7 n /2)ri- d' ciL
4.Date Well(s)Completed:og�1.j/2-L Well ID# . ft '�/ s ft. rti,� 6JV(� r I
5a.Well Location: /�(/J. rkt�]�5 I Z� ,�.0 ft, 3to5 tt 1_-. ...( 4 Soil' f�/(Jc
t +� � 1. ft. ft. 1�^' 7
Cr7Yt7AlelL'i at, G'S
Facility/Owner Name Facility ID:(if applicable) ft. ft. .
Zb TO A b k n f 1 a rg9 -, : AI C 2$c,5 c ft. ft.
Physical Address,City,and Zip/ ' �74/
1, ft. ft.
G-4-4. 1,v b 36 2 l 0 3�// 7 p¢��}IS I 21..REMARKS . . . . .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/ong is sufficient) 22.Certific 'on:
N w A
1.0.l.tA_g).4, 9/1.5/ (1
6.Is(are)the well(s)0Permanent or Temporary Signature of Certified Well Contractor, Date
By signing this form•1 hereby certify that the welt(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with!SA NC4C 02C.0100 or!SA:NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 CIS(-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: p SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z 6S. (ft) 24a. For All Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths ifdit ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing:40
warer level is above casing,use"+ (ft-
If ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection 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
m Air Flow �'
•
13a.Yield
(gpm) ��//l Method of test: 24c. For Water Supply&Infection Wells: In addition to sending the form to
Chlor Tabs 1 lrz Les 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. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource4 Revised 2-22-2016
1 i .