GW1-2022-00244_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: f
Robert Teague 14:WATERZONES:_....:;::
Well Contractor Name FROM ft. �Q ft.M TO DESCRIPTION
2857-A .5 Oft. ( b ft.
NC Well Contractor Certification Number ;
115;OUTER'CASING!foiimulti-ciised::e}t§'.OR LINER4 if' ))table
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft' ft- 6118 in. SDR-21 PVC
Company Name
:I INNERCASINGORTUBWG: eaUterriml_closed-loo `_;' :;, .:::`,.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Couno'.State.Variance,etc.) ft. It. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .d7 SCREEN1�:'
FROM TO DIAMETER SLOT SIZE THICKNESS AfATER1AL
Agricultural CiMunicipal/Public fa ft. in.
Geothermal(Heating(Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial E3Residential Water Supply shared ,
PP Y(shared) <'18:GROUT.ii:
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL
Monitoring Recovery
Injection Well: {[. ft
Aquifer Recharge DGroundwatcr Rcmediation
39:SAND/GRAVEL:PACK da lt6b►e ',
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [2Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20:DRILI ING LOG att�ch'9dditiooatslii e19:ifneces'"
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks) FROM To DFSCRIPTION(color.hardnesJZnos,sonlrock e, rein size,etc.)
ft, YS ft
4.Date Well(s)Completed:) Well ID# Li 5 1L deft.
5a.Well Location: ft.
3 ft. L
fL ft C
Facility/Owner Narif Facility ID#(ifapplicablc) ft. ft.
s u as rV,, �N\tY Mill ft.
Physical Address,City,and Zip ft. ft. L A V _�
a.,+' 0 tie'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Cert' oZIA
Nt W c/
6.Is(are)the well(s)oPermanent or OTemXand
Sienacuro ofCcrtificd Wc11 ntmctor Date
By signing this form,I hereby cerfiA that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes oo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fill out known well construction informatiplain the nature grthe copy ofthis record has been provided,'to the well owner.
repair under 421 remarks section or on the back of this jbrm.
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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:_ A
3�� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a!1 depths ifdifferent(example-3@200'and 2 ct 100') Construction t0 the following:
10.Static water level below top of casing:40 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" i ,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 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 of1this form within 30 days of completion of well
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(i.e.auger,rotary,cable,direct push.etc.) construction to the following �
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Services Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water SUDDIV&Iniection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above, also submit 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.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water RcsourcesRevised 2-22-2016
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