GW1-2022-00114_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' I
_ FROM "O . DESCRIPTION
Well Contractor Name 3—^p?s f:• •s t. ft. I t
2857-A 4 �:,_• R �:. f i
ft. ft.
NC Well Contractor Certification Number r n
DEC C 1 � 21,2_ 15.OUTER CASING for multi-cased wells OR LINER if a livable
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
F^^ r. ^1 Cl:v:`uF •. ,r. 0 ft. ft. 61/6 1O' SDR-21 PVC
Company Name Irlp>>`+ -"{"'
16.INNER CASING OR TUBING eothermal dosed400
2.Well Construction Permit# P'# �� 1 1. � FROM TO DTAM. TEA THICKNESS MATERIAL
List all applicable well construction permits(i.e.UFC,Cotoily.SIatC, arian e.etc.) ft. ft. /in.
3.Well Use(check well use): ft-
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SI7.E THICKNESS MA Al.
Agricultural nMunicipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) ft ft. in.
Industrial/Commercial 13Residential Water Supply(shared) IS.GROUT•
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUM
Non-Water Supply Well: ft. M
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwatcr Rcmcdiation '
19.SAND/GRAVEL PACK rtf a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL PLACEMENT METHOD
Aquifer Test [3StormwaterDrainage
Experimental Technology Subsidence Control tt. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM . .To DESCRIPTION(color•hardness. in type, rain size.etc.)
Geothermal(Heating/Cooling Coolin Return) Other(explain under?:21 Remarks) ft. ft.
4.Date Well(s)Completed:tm'r 11 ID# fcra
. r.
Well Location:
Cft. ft.
Facility/OwncrName Facility ID#(ifapplicablc) ft. ft.
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Physical Address,City,and Zi ft. ft.
2L REMARKS
la
County' Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio
N W Ad
6.Is(are)the well(s)oPermanent or Temporary Signature ofCcrtificd Well Contractor Date
Jnd�, ainthenaiureqfihe
4v signing this form,1 herebv c'ertiJv that the u'ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [Dyes or , with 15.4 NCAC 02C.0100 or 1514 NCAC 01C.0200 Well Construction.Standards and that a
/'this is a repair,fill out known well construction information copy'ofilds record has been provided to the s% onner.
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)nay also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well de elow land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(erample-3@200'and 2@100') construction to the following!
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10.Static water level below top of casing:40 (ft.) Division of Water,Resources,Information Processing Unit,
/'water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:,6 1/8 (in.) 24b.For Iniecton 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': j
(i.e.auger,rotary,cable,direct push.etc.) ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c. For Water SUDDly&,Iniecuun Wells: In addition to sending the form to
the address(es) above, also siibtnit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1l2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmcntal Quality-Division of Watcr R_' OLL J Revised 2-22-2016
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