GW1-2023-01858_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robed Teague 14.WATER ZONES�%:.`.","
FROM TO DESCRIPTION
Well Contractor Name itt
2857-A
9,
NC Well Contractor Certification Number
FEB CA SING'& ANEK(if fat dW.ells) L licable),
B&K Well Drilling Inc ifl � pmv
FROM I TO DIAMETER 1 THICKNESS I MATERIAL
fL 11 -7 6 118 SDR-21 PVC
Company Name I
:16AP 'ASING OR ING(jeaffi ��
ernidlf]09 ��
2.Well Construction Permit#:�,kw FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State.Variance,etc.) it. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft. in:i
:)Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ini,,
_11ndustrial/Cotitritercial [3Residential Water Supply(shared) i
I&GROUT.,.':
. . I
-JIrrigation FROM I TO I INIATERLAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
:iMonitoring DRecovery I ft. ft.
Injection Well: ft. ft.
li
3Aquifer Recharge 13Groundwater Rcnicdiation
19.SAND/GRAVEL PACK(if applkable)
Aquifer Storage and Recovery [3Salinity Barrier FROM I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fL I
Experimental Technology 13 Subsidence Control ft. It.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additionsit sheets if neicestat
FROM To DESCRIPTION(mlor,ha&dneSS.!2!Kmck type. in Sim etc.)
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) f'.
I
4..Date Well(s)Completed: Well ID# It. ft.
51 Well Location: ft*
I U fL_- ft
RL;3_0� 7`5 ft.
Facility/Owner Name
Physical Address,City.and Zip ft. ft.
21.RFMARKS
4; nr '-J
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22iCle7i tion:
N W
Z7�
*
6.Is(are)the well(s)oPermanent or Temporary —Signature ofCcrfified Well Contrao r Date
kysigning this fi)rm.I hereby cerly�That the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or [)No with 15.4 NCAC 02C.0100 or 15.4 NC4C 02C.0200 Well Construction Standards and that a
!'this is a repair,fill out known well consirucliki rmatior and arplain the nature ofthe copy cy"this record has been provided to!the well owner.
repair under#21 remarks section or on the back of this 1:
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also lartach additional pages if necessary.
drilled: .4 SUBMITTAL INSTRUCTIONS
.A-
9.Total well depth below land surface: 7n—
Jft-) 24a. For All Wells: Submit thi§form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water ResoIrces,Information Processing Unit,
If water level is above casing,use 1617 Mail Service 6eri,ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For infection Wells: In additi6n 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
construction to the following:
(i.e.auger,rotary,cable,direct push.etc.) Division of Water Resources,Underground Injection Control Program,
I
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Suably&Iniecti I Wells: In addition to sending the form to
the address(es) above. also submitone copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to[ the county health department of the county
- where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Rcsourccs� Revised 2-22-2016