GW1-2022-00117_Well Construction - GW1_20221219

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: f
Robert Teague 14:WATER ZONES* :.
Well Contractor Name FROM 'to DEscRirnoN
2857-A L ft. ft. i
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a ncable
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ft. 6118 In' SDR-21 PVC
Company Name
76.INNER CA G OR TUBING eothermal dosed loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL '
List all applicable well ronstrucion permits(i.e.UfC,County.State, Parianre,etc.) ift. ft• j!Q
3.Well Use(check well use): ft. ft.
Water Supply Well:
„17.,SCREEN
FROM TO DIAMETER SLOTStZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in.
Industrial/Commercial OResidential Water Supply(shared) -.
IS.;GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD B AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge oGroundwatcr Rcmediation ft ft.
19.SAND/GRAVEL PACK lfa' licable'
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL T•EMPLACEME\T METHOD
Aquifer Test [IStormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) EiTracer 20.:DRILLING LOG attahc additional sheets if aecessan
Geothermal(Heating/Cooling Return) MOther(explain under 921 Remarks) FROM 1.0 DESCRIPTION(color,baqlnez.soil/rock type, rain size,etc.)`
ft. ft.
4.Date Well(s)Completed:11- Lq -Well ID# ft ft.
5a.Well Location:
ft ft.
JS
Fadlity�crNamc Facility ID#(if applicable) ft ft a
Physical Address,City,and Zip —�-�^ ft. ft. I C
r- p
ID© 'Lt1 ti t{ 21.REMARKS'
County Parcel Identification No.(PIN) I - ,-7r.=iin') '.,�r•.� c
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Certiftca'
i
N W l ^ F
6.Is(are)the well(s)oPermonent or Temporary ignatruc of Certified Wcll Con ct Date
ply sihaing this farm,I hereby cert6 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or o w•irlr!5A NCAC 02C.0100 or 15.4,NCAC 01C.0100 Rell Construction Standards and that a
lfthis is a repair,fill out known well construction information nd plain the ratw•e gfthe copy o(this record has been provided m the well owner.
repair under#21 remarks section or on rite back of this form. i
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 inay also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ 20� A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifti ferem(erample-3@200 and 1@100') ConStiUCtlOn[0 the following:
10.Static water level below to of casing:40
P g (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use '�" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For infection Wells: In;atidition to sending the form to the address in 24a
12.Well construction method Rotary Air Rota above,also submit on l e copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push.etc.) construction to the fol owing: I
t
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield m . r ow
(gP ) � Method of test. Ai Flow 24c. For Water SuoDly&In Wells: In addition to sending the form to
Chlor Tabs t tl2 Lbs the address(es) above, also subinit 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.
Form GW-I North Carolina Dcpaitment of Environmental Quality-Division of Water Rcsol tees Revised 2-22-2016