GW1-2023-01912_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES-' '
_:�: 1 ;
Well Contractor Name FROM TO DESCRIPTION -
2857-A 05 ft. 3 j Qa ft. 2. 16 n
ft. - ft. 7
NC Well Contractor Certification Number 15.0 R CAS G forinulti aced' ells OR LINER if a Hcable
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft CY
t• 6 1/8 1', in. SDR-21 PVC
16.INNER CA ING OR TUBING eatiiei nisi closed4 r
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS T 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.
Water Supply Well: :-17.SCREEN- f
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) [@Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT:.:... . "
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring [DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Remcdiation
19.SAND/GRAVEL PACK if a Hcable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
g
Geothermal(Heating/Cooling RReturn) Other(explain under=21 Remarks) FROM TO DESCRIPTION(coloqrdness,soiltrock tre,grain size,etc.)ft. ft.
4.Date Well(s)Completed:\., D 1J.W.11 1D# ft.
Well Location: 0St•
Ly-b c (5 t_
Faciliry(Owner Name Facility ID#(if applicable) ft. ft
IJ` - ft. ft.
Physical Address,City,and Zip ft. ft. °wv f f �a6' F
21.RENIARKS e - n 'j.
County Parcel IdentificationNo.(PIN) 9, 2, 2Q23
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ I !"
(if well field,one lat/long is sufficient) 22.Cert
- 13r3t2iu�
N W �+�•' )-
6.Is(are)the well(s)oPermanent or OTemporary Ignaiure of Ccnificd Well tractor Date
4y signing this form.I hereby certyf thm the well(s)war(xere)constructed in accordance
7.Is this a repair to an existing well: []Yes or No with 15.4 NC.4C 02C.0100 or ISA NCAC.02C.0200 14-ell Construction Standards and that a
Ijlhis is a repair,fill out known well construction information a arplain the nature of the copy of this record has been provided 6 the well owner.
repair under#21 remarks section or on lite back ojthis form. 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft.)
c
( 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3@100 and 2 a 100') construction to the following: i,
10.Static water level below top of casing: 40 (ft I
Ijtoarer level is shove casing,use"+" ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (in.) 24b.For injection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form 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,JUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Suoaly& Iniectio I Wells: In addition to sending the form to
the address(es) above, also subn1itlone copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1t2 Lbs completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016