GW1--05514_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 4.
Robert Teague 14.WATER ZONES i' •
Well Contractor Name FROM TO DESCRIPTION
2857-A • 1--S �' ? C It• ', G�)t•-
NC Well Contractor Certification Number �3-� 7 aft. �! I/ �`
15.OUTER CASING(for.malti-talk ells)OR LINER(if ap licable)
B &K Well Drilling Inc FROM 1.7 DIAMETER THICKNESS MATERIAL
Company Name 0 ft. G ft. 61/8 In• SDR-21 PVC
16.E INNER CASING.OR TUBING(geuthernialilosed-loop)`` • ' .
2.Well Construction Permit#: S W.. I ' 0 o.SC4 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use):
ft. ft. in.
Water Supply Well: 17.SCREEN I • _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural , DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. :in.
OIndustrial/Commercial ®Residential Water Supply(shared) 18 GROUT: •
I I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
0Monitoring DRecovery ft. ft. i e`si,', , l�
Injection Well: '
0 Aquifer Recharge ®Groundwater Rcmcdiation ft. ft. I �"5 +/ �'
(+ w
Aquifer Storage and RecoveryOSalinityBarrier 19.SAND/GRAVEL PACK(if applicable) J EP.i • a6,)
FROM To MATERIAL EMPLACEMENT MUIIROD
0 Aquifer Test 0 Stormwater Drainage ft, ft. l' 1Rfrs:i?ry; c4;1 of .
Experimental Technology 0 Subsidence Control ft. ft. I L`'�`f ri;,�,, "''+iJ
m
®Geothermal(Closed Loop) ,Tracer 20.DRILLING LOG(attach additional sheets If necessary) ,• .
QGeothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color.hardness.soil/rock type,grain size,etc.)
( gJ g ®IOther(explain under#21 Remarks) 0 ft. f/ G ft. _I . ( ,t , cii((
4.Date Well(s)Completed:?'S--2Li Well ID# r d 4 ft' 2 b•$R. /� <
5a.Well Location: ` 'DO _ 41.0 77q- 1,.� ,,, C G c + �-
L b c.t..1 '0 0�1 G,i-Q 21 C_ I-Il.b e-,�`-#t.So- lG+.t-t 1 t -
Facility/Owner Name Facility ID#(if pplicablo) ctC/)Oft• 1_.- C J)/G Sr�4 ni.��l
> > �o v(;;•) �ctrA n -JJ Nc�� ft. ft. vV
Physical Address,City,and Zip ft. ft.
f ec)n La) 21::REMARKS . . . ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one latllong is sufficient) 22. ifrca
N W Cert- 7 ' , ay
.y....-.....
6.Is(are)the well(s0 Permanent or OTemporary Signature of Certified Well Contra Date
By signing this fom, I hereby cert)/y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or No with 1SA NCAC 02C.0/00 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information an 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �.e)� 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-3C200'and 2 /00') construction to the following:
40 '
10.Static water level below top of casing: (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 Injection 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
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resource[IsdUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I s� Method of test: Air Flow 24c.For Water Supply&Inflection 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 Water Rcsourc Is Revised 2-22-2016