GW1--06662_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.wATERZONEs i I '
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FROM TO I DESCRIPTION
Well Contractor Name
2857-A S c. ft• a L at. 2,1 I G,?sf,
5Q ft LLB
NC Well Contractor Certification Number 5 ft. ,
kil 15.OUfER CASING•(for-multi )OR LINER riff limbic)
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 , ft• >ft• 6'1/8 in• SDR-21 PVC
16.INNER CASING OR TUBING(geothermal•elased400p). ' _
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity.State.Variance.etc.) ft ft in.
3.Well Use(check well use): ft ft, ;n
ater Supply Well: 19:SCREEN - .
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�MunicipalPublic ft. it. 1 in.
thermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft in.
Industrial/Commercial °Residential Water Supply(shared) •is,GRUIIT; ;:'.
Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring 0Recovery ft. ft.
Injection Well:
ft.
Aquifer Recharge . .°Groundwater Rcmcdiation ft I
Aquifer Storage and Recov : 19:SAND/GRAVEL PACK(if applicable)
cry OiSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft ft
Experimental Technology 0Subsidence Control ft ft
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach sddidonai sheds ifneceuuy):.i: ', .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRI ON(color.ha e�miff type gran size.eel)
�f' oft" G.� IC) ; d 6
4.Date Well(s)CompletedIV)- 2 Well ID# 6 Sit. Q fir.-1__ r 1 /j/ im
5a.Well Location: V ft JiL, i� c/ram! �a,r
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i ki c�,aC\ \j , i-c_ ft ft.
Facility/Owner Name Facility IDO(if applicable) ft ft. . t,� - a•
LJ V U 1 c.rv.1 L, ft. ft. ° •
Physicall Address,City,and Zip ft. ft N U V 2024
2--A , \LC��6� 2L.REMARKS. , . '
County .1r:`.-J, r .� —....
Parcel Identification No.(PIN) rl ':•.-,:-;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) •• 22.Ce a _ I.
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N W /1t✓�E ! L).211u�
6.Is(are)the well(s) Permanent or Temporary . Signature of Certified Well Con r !to !
13y signing this fart,I hereby certify that the no!/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or o with 15A NCAC 02C.0100 or 1SAl'NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and lain the nature of the copy of this record has been prodded to the well owner.
repair under#21 remarks section or on the back of this form. !'
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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may'also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth low land surface: S d ' (ft-) 24a. For MI Wells: Submit this form within 30 days of completion,of well
For multiple wells list all depths rfdifferent(example-3@200•art 2@l00') .
construction to the following: f
10.Static water level below top of casing:40 • I
limiter level is above casing.use"+" (ft.) Division of Water Resources,Information Processing Unit,
6 /8 1617 Mail Service{Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in,)
24b.For Injection Wells: In'addition to sending the form to the address in 24a
12.Well construction method: Air Rotary N. above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary, push, ) I
construction to the following:
cable,direct us etc.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
W 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&lni
V ection Wells: In addition to sending the form to
13b.Disinfection type: Chloe Tabs 1 1/2 r.bs the address(es) above, also submit one copy of this form within 30 days of
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 2-72-2016