GW1-2022-05710_Well Construction - GW1_20220609

PrInt F
WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague A-VlATE.R:ZDvt
FROM TO DESCRIP7TON
Well Connector Name � �S ft.B 8r K Well Drilling Inc ft. rc.
NC Well Contractor Certification Number - -
>15::OJ'GEit:GtL571!IG tiiattieased hells ffK13N�.12'iT .
2857-A FROM TO DLAMETER THICKNESS MATERIAL
0 ft. fL 61/8! in. SDR-21 PVC
Company Name
�� y 161hNER`' G:flR Fil$Ii3G: cloxtf,loo' :, .
2.Well Construction Permit#: IL FROM TO 01A.METER THICKNESS MATERIAL
Lisa all applicable mull cowtsrrucrion perntus ll.c,U1C.Cowin,Stale. Variance,ett.) ft - o t4 (r T) in. C t
3.Well Use(check well use): ft. ft. in.
Water Supply Well: a7::SC3fE£�r,;:
Ppy FROM TO I DIAMETER SWTFIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft ft.
Geothermal(Ticating/Cooling Supply) Residential Water Supply(single) tL ft.
Ind ustrial/Commercial Dkesidearial Water Supply shared
P Irrigation FROM TO NMTERLAL EMPLACEMENTIIIETHOD&.AMOUNT
Non-Water Supply Well: ft. fL
Monitoring QRecovery ft. ft.
injection Well:
rc. ft.
Aquifer Recharge Groundwater Remediation
i9:St13V)37Ci29:Yt'4:4.f,K 9cable
Aquifer Storage and Recovery DSaliniry Barrier FROM TO ALATERLAL EMPLACEMENT METHOD
r3Aquifcr TCst [3Stormwata Drainage
PExperimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 2i#'3TItIiEINGI OC:attich.aili5fieslsliPeisa€
BGeothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRIPTION color bare ss sotur«1 R ereln size.e[e I
ft. ft.
4.Date Well(s)Completed-" Well ID# 3 ft. D it. �(�Y'
5a.Well Location:
1
a
ry Y�s ft. ft.
c
FacilitylOwnrrName Facility tDufifapplicable) ft. ft. „
�1o1 c3 '' L End Y ft. ft.
ft. ft
Physical Address,City,and ZipGCX y
S
County Parcel identification No.(PIN) D`t Qi 4 0G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laftne is sufficient) 22.Certification:
6.Is(are)the well(s)OPermanent or [3Temparary Sieatature ufCLnificd Weal CoraralKr Datc
Bt signing this form. 1 herelxi certify that the x-ellfq was(u-ere)constructed in accordance
7.Is this a repair to an existing well: 13Yes or No +ah 15A NCAC 02C.0100 ur 15A NCAC 02C.0200 Well Construction Sutndards and that a
If thi.,is a repair,ill our knoxn Nell consimcdon information and cplatn the native of die copy of/his rernrd has been provided to the well oeener.
repair under 921 remarks section or on the bark of this funn.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells havinr,the same You may use the back of this page to provide additional well site details or well
construction,only 3 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also 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 complel.iou of well .
For multiple wells list all depths ifdiffei-em(:rumple-3Ca,200'and 2@1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
if ewrer level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (in.) 24b.For Tniection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method. construction to the following:
(i.e.auger.rotary cable,direct puslL eta)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test Air Flow 24c-For Water Supply&Iniection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form «Rhin 30 days of
P
13b.Disinfection type:
Chlor Tabs Amount: 1 1/2 Lbs completion of well con�trucrion to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Rev,sed 2-22-2016