GW1--05508_Well Construction - GW1_20240912

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Robert Teague • >14:WAfER ONES-: •• i i 0 •
Well Contactor Name FROM TO DESCRIPTION
2857-A 3 mil.i $ vi`' .3.--,.3.--,/
C�S o ft.h( c ft. ZII J� iv,
NC Well Contractor Certification Number ) L!
15.OUTERCASING(for mui rcay wells)OR LINER(if li able) .
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft ,1 ft. 61/8 in' SDR-21 PVC
' :.16.'INNER CASING OR TUBING(geothermal-closed-loop) .
2.Well Construction Permit#:f.A WePLi--(),get0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County.State.Variance,etc.) fL ft. i' in.
3.Well Use(check well use):
ft ft. i in.
Water Supply Well: la:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
C3Agricultural DMunicipallPublic ft. ft. l in.
Geothermal(Heating/Cooling Supply) EllEtesidential Water Supply(single) fc fL in.
Industrial/Commercial Residential Water Supply(shared)
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft i
0 Monitoring °Recovery rt. ft.
i.
Injection Well: fL fL
DAquifcr Recharge . _ °Groundwater Rcmcdiation
• 19.SAND/GRAVEL PACK(if pp&gble) '
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test 0 Stormwater Drainage ft. ft
Experimental Technology D Subsidence Control ft. ft.
DGeothermal(Closed Loop) °Tracer 20.;DRILLING LOG(attach additioasIsheetslfneeesaaey)::'` .•:. . .:.11 .
FROM ,
DGeothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) TO DESCRIPTION(color.hard soii/rncktvpe grain size Na)
C) ft493 dI'r71 . cit
4.Date Weil(s)Completed?.2 J-2- j Well ID# (z3ft' ft. h usyri iliCt .siCtr.‘ -k.`
5a.Well Location: ''ab 9t Llo5 ft 1.,, l 5 o U.Q_
Ykolttiian l� i(C k. (<&cJ— Li o 7 o_Cm y c- 'J ,egi ' ".
Facility/Owner Name. Facility ID#(if applicable) ft f
F. 9 e...
3 )9 F� 5 10.( U,, 1 ci ft. ft. � �
.:a n• 4...L.)
Physical Address.City,and ip ft.. ft S C P 1 2 20 7g
/ / , C-0 J1/1 6 2L:12EMARKS .
37MQ.'7.41 Um
County Parcel Identification No.(PIN)
L ly w _
1.ii+i1C9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
42 7 3-��
6.Is(are)the well(s)�Permanent or Temporary Si a of Corti cd Well Contractor Date - •
By signing this form,I hereby certh that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or�No with 15A NCAC 02C.0100 or 15A NCAC.02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information an plain 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. i , .
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same • You may use the back ofthis1page to provide additional well site details or well
construction,only 1 W-I is needed. Indicate TOTAL NUMBER of wells construction details. You may1also 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 wells list all depths if different(example-3C2a 200'and 2@/00') construction to the following: .•
10.Static water level below top of casing: 04 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail ServicelCenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For infection Wells: lnii 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, push, construction to the following: 1
rotary,cable,direct etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,Raleigh,NC 27699-1636
it41 ,
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&In iection Wells: In addition to sending the form to
Chloe Tabs 1 1/2 tbs the address(es) above, also subinit 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016