GW1-2022-00115_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I ,
Robert Teague la:WATERzoxEs' t
Well Contractor Name '-• FROM TO UESCRIPI'ION
1•.
ft. ft.
2857-A 2�2�
O r C i ft. ft.
NC Well Contractor Certification Number
x,. r 15.OUTER CASING for'muld-cased wells.OR LINER if a livable
B &K Well Drilling Inc s; ur"'
1f1�,f�L„';S�l: f.y FRUM To
DIAMETER THICKNESS MATERIAL
Company Namercllg�
ft. 61%8 iI" SDR-21 PVC
�� . 16:INNER CAS
INGORTUBING: tiothermatelosed-loo
2.Well Construction Permit#r .i W��'O FROM TO DIAMETER THICKNESS hATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.) ft. in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOTSIZE THICKNESS 1fATERIAI.
Agricultural [)Municipal/Public ft. ft. in.
Geothermal(HeatingiCooling Supply) OResidential Water Supply(single) fL fr. in.
IndustriaUCommercial Residential Water Supply(shared)
"18.GROUT" . .... _
irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. "
Monitoring DRecovery
Injection Well: ft. fr.
Aquifer Recharge Groundwater Remediation
FROMANDIGRAo L PACK licable
Aquifer Storage and Recovery [)SalinityBarrier MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 10.DRILLING LOG aftich'additionalsheets if rieces -
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) I
FROM 1'O DFSCRIPTION(color.bardnem soillrock type,grain sizes etc.)
fL C S ft.
4.Date Well(s)Completed: •ell ID# ft. fr.
' ..S
5a.Well Location: ft. S fVIA-
t•
11pt Il^f t 11y_ � f4 ft.
Faci'ty`lo Acrr Manic Facility ID#(if applicable) fL ft.
1 i e '�I.t
Physical Addnss,City,and Zip ft. ft.
21,REMARKS
'� �Y� gays.77
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one latllong is sufficient)
22.Certificatio_•.
N I.W
6.Is(are)the well(s)oPermanent or Temporary Signature ofCcrtiftcd Wcll Co ct Date
13r.signing this form,l hereby certify that the ue11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes orIN wirh 15.4 NCAC'02C.0100 or 15AWCAC 02C.0100 Well Construction Standards and that a
1f this is a repair,fill out known well construction information and explain the nature qf the copy ofthis record has been prncided to the well owner.
repair under#21 remarks section or on the back ojthis form.
23.Site diagram or additional well details:
S.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 depth below land surface: (ft-) 24a. For All Wells: Submit'.this form within 30 days of completion of well
For multiple wells list a!1 depths if different(example-3@200'and 2@100q
construction to the following: ;
10.Static water level below to of casin 40
P g� (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection Wells: Inladdition 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.
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Serv'I a ICenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water SuoDly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1t2 Lbs completion of well construction Ito the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016