GW1-2022-00242_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES I i
Well Contractor Name FROM TO DESCRIPriON
2857-A /"/"Dt-Ir
'
ft. r'ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-ca d ellsR LINER if a Ifeable
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ft. 1 6118 in. I SDR-21 PVC
Company Name
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.) ft. As ft. in.
3.Well Use(check well use): ft. fr. rn•
Water Supply Well: 17.SCREEN '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial E3Residential Water Supply(shared) 1K GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT '
Non-Water Supply Well: fL ft.
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Rcmcdiation ft. ft.
19.SAND/GRAVEL PACK ffa licable'
Aquifer Storage and Recovery ®ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additiooal sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under t21 Remarks) I FROM 1 11.0 UFSCRIPTION(color,h4rdness,s Rlmck type,grain size,etc.)
fL S ft. �
4.Date Well(s)Completed: ell M# �ft, a� I.
55a(..Well
Location: a Sft• ft-
I�_l) j l ft. ft.
Facility/Owner Name Facility ID#(ifapplicabblc) ft ft. vc- V� ,\
�--���`� S' 1 �l _C p C�ll►Yt lr1 �cl ft. ft. ;'V
P sieal Address,City,and Zip ft. fL
1�.
7
I 21.REMARKS`'.' � ::. .. ...
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one Iatllong is sufficient) 22.Certificati
N W P 16
6.Is(are)the well(s)oPermanent or [3Tempora SLw6turc ofCcrtificd well Contactor Date
4v signing this Jbrm.I hereby certyy that the well(.$)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or No with 15.4 NCAC 02C.0100 or 15A NC•AC 02C.0100 lVell Construction Standards and that a
If this is a repair,fill out known well construction information d plain the nature of the copy of this record has been provideU to the is-ell owner.
repair under#21 remarks section or on the back of this form.
r
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 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: 14
3 SUBMITTAL INSTRUCTIONS
9.Total well de claw land surface:_ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iird yTerent(etaniple-3@200'and 2@100� Construction[0 the following: j p
10.Static water level below top of casing:40 (ft
Division of Water Resources,Information Processing Unit,
Ifwater 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 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:
Division of Water Resourcles"'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: Air Flow 24c.For Water SuoDiv&Infection Wells: In addition to sending the form to
Chlor Tabs 1 112 Lbs the address(es) above, also sirbinit 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 Department of Environmental i p Quality-Division of Water RcsoI rccs Revised 2-22-2016