GW1-2022-00241_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD(GW 1)
For Internal Use Only: I
I.Well Contractor Information:
Robert Teague r
la.warERzoNEs:::: _
Well Contractor Name
. •
-77
FROM TO DESCRIPTION
2857-A ft• �� ft.
NC Wcll Contractor Certification Number ft `'V ft. r t
B&K Well DrillingInc IS.OUTER CASING ftic:aitit7ti. se:w OR`L1NER tfa lica6le
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. ft. 6 118 1 in.
SDR-21 PVC
ER ING:ORTMING eoiherm :close&Ioo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CbuntY,State.Irariance,etc.) ft. ft. L& n.
3.Well Use(check well use): ft. ft. n.
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERU
[3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) I@Residential Water Supply(single)
Industrial/Commercial ft ft. in.
Residential Water Supply(shared)
Im ation ]S:.GROUT
FROM Non TO MATERIAL EMPLACEMENT METHOD&4MOUNT
-Water Supply Well: ft. ft
Monitoring Recovery
Injection Well: ft• ft.
Aquifer Recharge Groundwater Remediation ft ft.
19.SAND/GRAYED PACK da lica6le
Aquifer Storage and Recovery
Salinity Barrier Aquifer Test FROM TO MATERIAL
EMPLACEMENT METHOD
�IStotmwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer
20.DRIIiL1NG'LOG attsch'ailditidnai5lieets -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ro DF'SCRIP f10N(color,ha ess sotUrock tv e, rain size ere.)
_ ft• ft.
4.Date Well(s)Completed: _Fell ID# ft. ft. .
5a.Well Location:
4FaciliwncrN c ft F ) T
Facility ID#(if applicable) ft. fL
W 1 s YVflT1 Pr r. i�Physical Address,City,and Zip ft. ft
\� c _
21:-REikIARKS:.: . - .. •,:.. ,:: : r ::.:..
Coun,�ty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient)
22.Certific on• '
N W
6.Is(are)the well(s)oPermanent or OTemporary /
Sienaturc ofCc c ll Contra Date
4v signing this form,I herehv ceriify that the well(T)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or o with 15.4 NCAC 02C.0100 or 1511 NC.4C 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction informatianAdplainihenalureof1he cuPY of III&record has been provided to the i+ell owner.
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 ito 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:
—1 7 �'�� SUBMITTAL INSTRUCTIONS
9.Total well depthelow land surface:b (ft.)
For multiple wells list all depths ifdferent/example-3@200'and 2@100') cons For All Wells: Submit this;form within 30 days of completion of well
construction to the following: '
10.Static water level below top of casing:40
/'water level is above casing,use"+" (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) i
24b.For Iniection Wells: In addition 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 3D Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 tl2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-
I 22-2016