GW1-2022-00233_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Robert Teague 14.WATER ZONES
FROM TO DESCRITON
Well contactor Name LS R 1,2 a R /1-M
2857-A 3 s aR L D. 12
NC Well Contractor Certification Number 73.OUTER CASING forma wdb OR LINER B k
Q B K Well Drilling Inc FROM TO DIAStiTER iRICRNP65 MATERIAL
0 R. t R 6118 1n. SOR-21 we
Company Name lf.DINEilCA9R4G OR TUBING
2.Well Construction Parrott M: FROM TO DIAMETER THICKNESS MATERIAL
Litt all applicable Hell construction palmier 0 c UIC.(imam.State. Variance,etc.) ft. it. in.
R R in.
3.Well Use(check well on):
Water Su Well: n.SCREEN
Supply FROM TO DIAMETER SLOT SIZE THICKNGK aIATEPIAi.
Agricultural �MunicipaDPublic R fL iu
Geothermal(HeatinglCooling Supply) @Residential Water Supply(single) R, R I&
IndustriaUCommercial ❑Residential Water Supply(shared) I&GRM
irri irrigation FROM TO MATERIAL EMPLACEMENT METHOD&lk.MloT
Non-Water Supply Well: R �S R c�
Monitoring QRecovery ft. R.
Injection Well: R, R
Aquifer Recharge aGroundwatcr Rcmcdiation if LANDIGRAVLL PACK
Aquifer Storage and Recovery Salinity Barrier mom TO MATERIAL EMtutE+sexr METHOD
Aquifer Test ❑Stormaater Drainage R. R
Experimental Technology Subsidence Control R• R
Geothermal(Closed Loop) QTmcer 24.DRILLING LOG attach additional sheets If -
FROM TO DF_SCRI ION(mbr.hardam miarrs\w in ds aer.
Geothemtal Hearin Coolin Retumj Other(explain under 421 Remarks) fit. R s oZ 1-
-
4.Date Wells)Completed:-y:��Well IDa ft. 5 R. t / •-
L
s..coca motion: h. R
,6 R R. [(_
Faeiliry/ caner lame r~ Faeiliry 1 'fapplicable) R R
Iue_ C1 .xr . 1 Lepn y -
R. R n•
Physical ddreas,City,and Zip
2I REMARKS---------------
•s-.•'.;
JIG
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutesiseconds or decimal degrees:
(if well field one IaVlong is sufficient) 22.CertlG
'N W I t q �2
6.Is(are)the well(s)OPermanent or OTemporap'
greater of Cartifid Well Conn Data
`�a.a�'_� Br signing This form.1 hrnhc crrlify that the urllltt x'ar(were)cnnarvned in urrnrdmcr
7.Is this a repair to an existing well: OYes or/"�No xith 15A,NCAC 02C.0100 or 15A NCAC 02C.0200 Well Contraction Standards and that a
if this is a repair,fill out knaxm xell construction inforneatinarongrr®can -plain the nature afthe Wy afthis record has been prewded in the nrlI an nrr.
repair under 921 remark section or on the back ofthis form. 23.Site diagram or additional well details:
S.For Geoprobe/Dler 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 W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: A
) SUBMITTAL INSTRUCTIONS
9.Total wellda below land surface: "1 (R.) 24s. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths i(dperenl(a-ompJ—T200'turd hg100') construction to the following:
10.Static water level below top of casing:40 (D.) Division of Niter Resources,Information Processing Unit,
Ifxater level is above raving.use--" 1617}tail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: 6 1(8 (in.) 24b.For Injection 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
Il Well construction method: construction to the following:
(i.e.auger,rotary,able,dirxt push.etc.)
Division of Water Resources.Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
l31s.Yield(gpm) Method of test: err Flow 24c.For Water Supply& Injection 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: 1 112 I.Jea completion of well construction to the county health department of the county
where constructed.
Forth GW-I Sonh Carolina Department of Emironmenul Quality-Division of W'atcr Rcsaurca Revised 2-22.2016