GW1-2022-00110_Well Construction - GW1_20221219

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: }
Robert Teague 1,14 WATER ZONES.:-.`:;:..:!:
Well Contractor Name FROM TO UtSCRIPCION
2857-A ��t• (, % I
ft. ft
NC Well Contractor Certification Number
SS OUTER CASING:for_muld-cased wells OR.LINER.if " !le'able
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft I Sft. 61/8 in. SDR-21 PVC
.`76-JINNERCASINGiOR'I'.UBING+ e'othermalocloied=loo
2.Well Construction Permit#: �rA1 I'��- (>dry d, J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County•,State.Variance.err.) ft. � ft l in.
3.Well Use(check well use): fi. ft.
Water Supply Well: .. °;.:,1:7:SCREEN;;'.. :. .: .;..:. . ... -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural 13Mtmicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft, i in.
Industrial/Commercial Residential Water Supply(shared) 8-.GROIIT:':
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring Recovery
Injection Well:
ft.
Aquifer Recharge Groundwater Rcmcdiation ft
19:SAND/GRARELTACK d'a like
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT'4tETHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology ®ISubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ;20.DRII LING'LOG:ittsch'idditiotislslieem if ueces
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) FROM ro DFSCRIPrION(color,hardness saiUrocktype,' rasa Size etc.)
4.Date Well(s)Completed:I lU 12 2a Well ID# ft ft
5a.rrW((ell Location: t. ft S
ht'A Ih � ft. ft.
r
Facility/GwnerNamc �— Facility lD#(ifapplicablc) ft. ft
L,lc>l N rc l 1, h ( rcck. C�l^.
Physical Address,City,and Zip ft. ft
LJ
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Inwe,� 3�1 rgf(`GySP,��11E
(ifwell field,one Iattlong is sufficient) 22.Certification: 11 J uvh�,
N ---LW
zJ
1 -1�-
6.Is(are)the well(s)oPermanent or 13Temporary Signarurc of Certified Well Contrac Date
r
Br signing this form.I hereby certify that the well(.$)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!'this is a repair,fill out known well construction information nd plain the nature ofthe copy tjthis record has been provide(/to the net!otrner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additionallweli 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:_ 6 .^ `
CtJ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For mu (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
multiple wells list all depths ijdi,jJerent lerample-3@200'and 2 Q/00')
construction to the following: i
10.Static water level below top of casing:40 I'water level is above casing,use-+" (ft.) Division of Water Resources,Information Processing Unit,
Ji
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For lniection 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: I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield m Air Flow 1.
(gP )-- l Method of test: 24c.For Water SunDly&Iniecttlon Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 t/2 Lhs completion of well construction to the county health department of the county
where constructed.
r
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources
Revised 2-22-2016