GW1-2022-00113_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague 14 WATER ZONES:' (
Well Contractor Name e� ua� FROM TO DESCRIF71ON
2857-A f a ft. It-
NC
" b ft. I
NC Well Contractor Certification Number D E r" 1 202Z ! v
15.OUTER CASING for multiAM ca d wells OR LINER if a Usable
B &K Well DrillingInc �*�^ s R3f,
U ' FROM TO DIETER I THICKNESS MATERIAL
�,t1e�1.i�J.3 0 ft, I Cf5 ft. 1 61/6 ln' 1 SOR-21 PVC
Company-Name
�1 r 16.INNER CASING.OR TUBING' eothermal dosed400 ><
2.Well Construction Permit#• d sq 3 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State.Variance,etc.) ft. ;� ft- in.
3.Well Use(check well use): ft ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fa ft. in,
Industrial/Commercial Residential Water Supply(shared) -
PP Y( 18:GROUT...,.. . ,. •, ... .,
Industrial/Commercial
ation FROM TO MATERIAL EMPLACEMENT 51ETHOD&AMOUNT
Non-Water Supply Well: ft. ft. i '�
Monitoring ORecovery ft, ft.
Injection Well:
ft. ft.
Aquifer Recharge E)Groundwater Rcmediation
19:SAND/GRAVEL PACK ..applicable ..
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. I ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach'additional sheets if 6e6ei
Geothermal(Heatin Coolin FROM .1.0 DESCRIPTION(colarardnm%sotUrock type. rainsUs .3 Return) Other(explain under#21 Remarks) tL tt.
i
4.Date Well(s)Completed: Well ID# IL
ft-
f6 f4
5a.Well
\Location:
l
��1 J 7 � !�� �r •tC.F7 T L ft. ft.
Facility/Owner Name Facility lD#(if applicable) fL ft.
�.•. 1 � 1 1
`{ ft.
Physical Address,City,and Zip ft
'21.RE11•IAItKS.:: .-. .. .-.. `. . .:.:... .... . ...,:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wilting is sufficient) 22.Cerl' tion:
N W -6 -o
6.Is(are)the well(s)oPermanent or E3Temporary rgnaturc of Certified Well Contra r Date v
4v signing this form,1 heretic cen#i that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or No with 15A NCAC 02C.0100 or I5A�NCAC 02C.0100 Well Construction Standards and that a
if this is a repair,fill out known well construction information lain the nature gfthe copy tfthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 I 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 de th below land surface: 4( — ft.
( ) 24a. For All Wells: Submit,this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(erample-.3@200'and 2@100') construction to the following: I
10.Static water level below to of casin 40
p g: (ft.) Division of Water Resources,Information Processing Unit,
lfwater,level is above casing.use"+" 1617 Mail Service�Center,Raleigh,NC 27699-1617
i6 1/8 I I
11.Borehole diameter: (n.) . 24b.For infection Wells: Inl,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 push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servicel Center,Raleigh,NC 27699-1636
it
13a.Yield(gpm) Method of test: Alr Flow 24c.For Water Suoolv&lnjection Wells: In addition to sending the form to
Chllir Tabs 1 1/2 Lbs the address(es) above, also submit 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. II
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Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016
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