GW1-2023-01909_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague
-14.-WATER-Z0NES4,'.­:'_' 1' ......
Well Contractor Name FROM TO I DESCRIPTION
2857-A [7�/--
• ft. ft.
NC Well Contractor Certification Number
AS.-OUTER CASING(foebiulti=caied,,weNTHICKNESS
LI
B&K Well Drilling Inc FROM I TQ DIAMETER T"g L, S MATERIAL
Com an Name 0 6 1/8 1: In. SOR-21 PVC
:16.'INNER'C-99INGOR-,TUBING,(gtottkier
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) ft. fL i. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: �,.117.:SCREEN,.';
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
-lAgricultural [3Municipal/Public ft. ft. in..
:3Geothermal(Heating/Cooling Supply) [@Residential Water Supply(single) ft ft. in.
Industrial/Commercial [3Residential Water Supply(shared)
•:18.GR0UT.":
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
:3Monitoring 13Recovery
Injection Well:
3Aquifer Recharge oGroundwatcr Rcmcdiation
19.SANTIGRAVEL PACK Cifalatill6ible)
Aquifer Storage and Recovery [3Salinity Barrier
M TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft. i
Experimental Technology [3Subsidence control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additional sheets ifiiecissao),�
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM ft. TO DESCRIPTION(color,hardness.soil/rock type,grain size,etc.)
4.Date Well(s)Completed: Well ID# S ft. ft
ft-
5a.Well Location: ft. Los ft.
A= 60 al 0
7;-UN:S Sul ft. ft.
Facility/Ownc�r_Namc Facility ID#(ifapplicable) ft. ft.
(.kq
Physical Address,City,and Zip ft. ft. t 2 2
.21-REMARKS'�%';­
CL-,,A Xk sA
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22 Ce t*fl ti
N W
6.Is(are)the well(s)o Permanent or [3Temporary Signature ofCcrtificd Well 120tracro-r . Date
By signing this form,
i hereby cerfij�that the well(s)iras(were)constructed in accordance
7.Is this a repair to an existing well: JDYes or) .1
,kNo ivith 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
owner.
Ifthis is a repair,fill out known well constructionn rplain the nature ofthe copy ql"this record has been provided to the ire//vit/I
repair under#21 remarks section or on the back
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 attach additional pages if necessary.
drilled:
—A
9.Total well`dy eh below land surface: SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifel?fferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing.40
0'wvater level is above casing,use (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
61/8
11.Borehole diameter. (in.) 24b.For infection Wells: III addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of thisI Pan within 30 days of completion of well
12.Well construction method: 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: 1
1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supplv&Iniection Wells: In addition to sending the form to
. Chlor Tabs 1 112 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 ofEnvironinental Quality-Division of Water Resources' Revised 2-22-2016