GW1-2023-01893_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague
FROM TO DESCRIPTION
Well Contractor Name
2857-A
NC Well Contractor Certification Number
15i 011TER CASING Oo - L.ca bR T T; u011icable)'
B&K Well Drilling Inc FROM 1 TO EFIAMETER MATERIAL
Company Name 0 ft' lj<�� ft' 6 ll8 in' SDR-21 PVC
X"INNER CASING ORTUBING
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Zw--ater Supply Well: 47.,SCREEN­ 4
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
eothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial [3Residential Water Supply(shared) `:'l8.,GROUT`,..-,,1,`
I Ir
rrigation FROM TO MATERIAL EMPLACEMENT METHOD A,
Non-Water Supply Well: ft. ft.-
Monitoring DRecovery
Injection Well:
:]Aquifer Recharge E)Groundwatcr kemccliatRo'n
19.SAND/GRAVEL-PACK C if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology [3Subsidence Control
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additional sheets ifnecessary), 4'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.h-Onem soillrock 4,pe.grain size.etc.)
-ft.
4.Date Well(s)Completed: W.1110D# ft.
IL
5a.Well Location:
6, <> It
N-ility/dVJncr�slar�e­ v Facility ID#(ifapplicable)
ft Efft.
� 5 LAM) I-)
Physical Address,City, ad�ip ft. ft.
-202
2I.:RENIARKS:'.7'­..., FEB 4, P,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r,,N1d1QMC_:
(if well field,one lattiong is sufficient) 22.C ei
N W . 17�� , .
6.Is(are)the well(s)o Permanent or [3Temporary %rgnEturc ofCcrtificd Well Con,06tor Date
By signing this form,I herebv certify ihal the ivell(v)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
If this is a repair,fill out known well construction informatiolXand 'lain the nature of the copy of this record has been provided to the svellowner.
repair under#21 remarks section or on the ba�ci ofthisfor..
_
23.Site diagram or additional well details:
k
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 f attach
tach additional pages if necessary.
-drilled: - -A � 1.
SUBMITTAL INSTRUCTIONS!
9.Total well da blow land surface: C1 n 5,
ft-) 24a. For All Wells: Submit this form-within 30 days of completion of well
For multiple wells list all depths 1fdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of caking: 40 Division of Water Resources,Information Processing Unit,
V'ivater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 1/8 (in.) 24b.For-Injection 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
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail,Service Center,Raleigh,NC 27699-1636
Flow
13a.Yield(gp-) Method of test: Air 24c.For Water Supply& InjectiI.on Wells: In addition to sending the form to
.I 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.
Form GW-I North Carolina Department of Environmental Quality-Division ofWatcr Resources Revised 2-22-2016