GW1-2023-01847_Well Construction - GW1_20230222

WELL CONSTRUCTION RU
COR"D QW-1
11-Well For Inte Contract,,
InfOrm2tion: rnal Use Only:
Robert Teague
Well Contractor Name
2857-A ft. E FROMon
R..
T
ft.
14C WCertification Number E3 3-C 5 4 5 ft.
FEB 9, 2 2023& K,Well Drilling Inc A C. rib
SING. r,
15a"OUTER '
Company Name FRONf TO
DIAMETERTHICKNESS MATERIAL
r ft. 61 SOR-21
A,--a. ,--i Fir,
2.Well construction Permit#: C�, Ex,ti, I
List all applicable well c I: I I 1 11 11: 1 9_- : EKCAASIIN TURING,, PVC
onstructionp j- -J TO
.c.UC, - �`6 FROM Cis
LOUnry,State,Vario;�c�e j HICKNESS M
etc.) DIAMETER
3.Well Use(check well use): ft. in. A RIAL
Water Supply Well: ft ft. in.
Agricultural A7.-S__
Geothermal E]MuniCipal/Public FROM TO DIAMETER"'
(Heating(Cooling Supply) oResidetial War-Supply(sing, ft SLOT SIZE THICKNESS MATERIAL
Industrial/COMMercial Residential e) ft. ft. in.
I
Irri anon Water Supply(shared)
•
._:.
Non-Water Supply Well: I8.'GR0UT_ 'k
FROM
MATERIAL ,Monitoring ft EMPLACEMENTM
HOD&AMOUNTRcovey .InJec On Wel:
fr ft.
Aquifer Recharge
or Storage and Recovery ft
Aquifer E]Groundwatcr RcmCdiation ft.
Aquifer Test Salinity Barrier 19.SAND/GRAVEL.PACK ifa M To cable
OStOrmwater Draina MTERFAL
Experimental Technology ge
z.vir EME, METHOD
ft. ft.
Geothermal(Closed Loop) 13Subsidence Control it. ft.
OTracer
21DRMLINGLOG attachadditiOnW-sh6eigif-
Geothermal(Heatin Coolie Return) Other(ex lain under#21 Remarks) FROM TO DESCRIPTI
ft. ON(C........ 5011frock Z.
4.Date Well(s)Completed: Dme�grain size,etc)
_Z& Well JD#
52-Well Location: ft.
ft ft.
F
PICA S//C
.?ci,i� ft.
HY/OvIncr Name ft.
Facility ID#(if-.ppi
iabl.) ft fL
p ft.
CIy,and�Zip ft.
ft. ft.
County
Parcel Identification No.
5b-Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one'at/long is sufficient)
22. ertir,
-------------�N
6-Is(are)the welf(s)oPermanent or OTemporary Si turc ofCcaificd Zs
7-Is this a repair to an existing well: signing thisfol-m, herehv certify that the 1t,as L)atc
ffthisis a repair,Jill out known well construction ir, tion "Ith 15,4NC.4CO2C.0100 constructed in accordance
Xn !N'plain the nature qf1he caPy of1his record or 15.4'VC4C 02C-0200'yell C011trIction Standards and that a
repair under#21 remarl's section Or On the back ofthis"arm. h1heenProvidedlo the well,osiwer.
I
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Site diagram or additional well details:YOU may use the back of this pace to pr6ide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER ER of wells construction details. YOU may also attach additional pages if necessary.
9-TOW well depth below land surface: SUBMITTAL INSTRUCTIONS
For multiple wells list all depthy
1fdifferen 1(erample-3@200 7 ,d 2@/�00,) (ft-) 24a. For All Wells- Submit this form
10.Static con
g struction to the follow w thin 30 days Of Completion of well
water level below top of casing: 40 ing:
Ywater level is above casing,use .. -
(ft.)
Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.ForHection�Wells: In addition to se'
12.Well construction method: Air Rotaryriding the form to the addresd in 24a
above,also submit one copy of this form Tthin 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,Unde
rground Injection Control Program,
13a.Yield(gpm) Method of test:Air Flow 1636 Mail Service Center,Raleigh,NC 27699-1636
24c. 1`1111,
7&In�ection�%Vells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs
1 112 Lbs the address(es) above, also submit one copy of this form within 30 days of
Amount:
completion Of well construction to the county health department of the county where constructed.
Form GW-I
North Carolina Department of Environmental Quality-Division OfWatcr Resources
Revised 2-22-2016