GW1-2022-00228_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD QW-1
For Internal Use Only: P�lhtfprri:
L Well Contractor Information:
Robert Teague
Wall Contractor NamE 14 WATER ZO
2857-A FROM To
UESCRIPI'ION
ft. / ft. 1 I
NC Well Contractor Certification Number •L �`
B&K Well Drilling Inc 1s- 3 ft. l y
FROM
fERCASING far multi-ca3 iwells ORLINER ffa licable
Company Name FRUM TO DIAMETER
ft. THICKNESS MATERIAL
kil0 O ft 61/8
2.Well Construction Permit#:Q Z �,� (� 7 7 16 INNER CASING:OR TUBING I SDR-21 PVC
List all applicable well construction ernuts ` 7 FROM TO th-1114l•atused-ltiu
P ( vrt Lounly,State.1'anance,etc.-�� '� fL DIAMETER THICKNESS =
3.Well Use(check well use): V tt. MATERIAL
I.1 C12� i
Water 15,upP1Y Well: fL ft. in.
Agricultural 17.SCREEN-
0MunicipaUPublic FROM TO
Geothermal(Heating/Cooling Supply) DIAMETER SLOTSIZE THICKNESS -MATERIAL
Water Su I ft, ft. in
lndustriaUCommercial PP Y(single) ft. .
Residential Water Supply(shared) ft
lrri ation `r18.GROUT ::5
Non-Water Supply Well: FROM ro
Monitoring ft. .
MATERIAL EMPLACEMENT 51ETHOD&AMOUNT
ft. ,.
Injection Well: Recovery
ft. ft.
Aquifer Recharge
OGroundwatcr Rcmcdiation fL ft.
Aquifer Storage and Recovery
Salinity Barrier 19 SANI)IGRAVEL PACK tfa IPcable
Aquifer Test FROM TO
�Stormwater Drainage ft MATERIAL EMLACNT `
Experimental Technology ft. P EME METHOD
Geothermal(Closed Loop) Subsidence Control
ft. it.
GeothermalIlea,' Coolin Return Tracer
FROM LLINGLOG attach'ailditionalsheets.ifne
Other(ex lain under:21 Remarks) FROM To DFSCRIPT'ION'(color,hard soiUra k n e, rain size,etc.)
4.Date Wells)Completed: - -�� ft. ft.
Well JD# ft.
15a-Well Location: ft.
ft.
Facility/Owner Name f ft
ID# c) ft ft.
Facility (ifapplicabl
3 r fL
1,< '�t (_•=-�� 'fix.:�t��a;�
Physical Address,City,and Zip C Y ft. fL
�.- J� ft. fL Co
County .21:REM D C 1
ARKS."'
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one laoong is sufficient)
22.Cert' t:ation:
N
W
or
6.Is(are)the well(s) pe�anertt Temporary SignatureofCcnificdWdI v NYC
tractor Datc
7.Is this a repair to an existing well: l�.,f{Yes or Br'•signing this form•112crehv certify that the ue11(s)was(xere)consnucfed in accordance
repair is a repair.Jill out known well construction information and N lain the nature ofthe copy 15.4 N record has Olen provided ro the we/[ t
xirh Oft NGtC 01Cs be,,or/5.4.NCAC 02C.0200 1. Construction Standards and that a
repair under#11 remarks section or on the back oelhis form.
o cater.
8.For Geoprobe/DPT or Closed-hoop Geothermal Wells havingthe same 23-Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER ofwells
drilled: construction details. You may also attach additional pages if necessary.
9-Total well epth below land surface: a S SUBMITTAL'INSTRUCTIONS
For multiple wells list all depths ijdiiferenr(etample 3@200 and 1@100,) (ft-) 24a. For AllWells. Submit this form'within 30 days of completion of well
10,Static water level below top of casing. 40 construction to the following:
lewarer level is above casing,use..+ I '
(ft) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1/$ 1617 Mail Service Center,Raleigh,NC 27699-1617
. (in.)
Air Rota 24b. For Injection Wells: In addition to'sending the form to the address in 24a
12.Well construction method. Rotary
(Le.auger,rotary,cable,direct push,eta-) above,also submit one copy of this form'within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underg'ound Injection Control program,
13a.Yield(gpm) Method of test: Air Flow 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Su 1 &Injecton Wells:' in addition to sending the form to
136.Disinfection type; Chfor Tabs the addresses) above, also submit one hs
Amount: 1 1/2 Lbs copy of this form of
where constructed.
completion of well construction t0 the cou within 30 days
Form GW-1 nty health department of the county
ructed. I
�
North Carolina Department of Environmental Quality-Division of Water Resources !
Revised 2-22-2016