GW1-2023-01913_Well Construction - GW1_20230222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
1.Well Contractor Information:
Robert Teague 14.WATER_ZONES
Well Contractor Name FROM TO DESCRIPTION
2857-A tt. ft. I
ft. ft.
NC Well Contractor Certification Number 1
15.OUTER CASING for inulti-caiedlwclls OR LINER Ka' ticable .'
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name o ft. [ 3 ". 61181 I in. SDR-21 PVC
Q 76:INNER''ASINC OR..
7 ING eottierulal closed-lao' '
2.Well Construction Permit#: 1 tor- DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC Counnn,State.Variance,etc.) ft. ft in.
I.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
17.SCREEN- '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft.' ft.
Geothermal(Heating/Cooling Supply) OResideritial 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. i-
Injection-Well:
Aquifer Recharge DGroundwater Remediation ft. ft
19.SAND/GRAVEL PACK if a llcable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [2Stormwater Drainage ft ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach addifionat sheets if necessa •:. ::.: :..
Geothermal(HeatinglCooling Return) rJOther(explain under 1,21 Remarks) FROM TO DESCRIPTION(color,hardqess.soillrock type.2rain size.etc.)
4.Date Well(s)Completed: _'_Q6 ID# ft. t. (Z
5 Well Location: I ✓ t �' �t�-1
��� � 1 l � ft ft.
Facility/Owner Name 1 Facility ID#(ifapplicable) ft ft
WLIA 14116,
Physical Address,City,and Zip ft. ft
CCh L1 1 ( 716
J d 16 'Tt 57J.4 C.y ZI.REMARKS 2 � 3 _
County Parcel Identification No.(PIN) l_!P.td
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees:
(if well field,one lat/long is sufficient) 22.Cer tifeca n:
v W
6.Is(are)the well(s)oPermanent or OTemporary Signature ofCcrtificd Well Contract Date
,,,,,........,,,,
Br.signing this 1brm, 1 hereby ccrlJb•that the ivell(s)was Nere)constructed in accordance
7.Is this a repair to an existing well: []Yes or t(No with 15.4 NC.4C 02C.0100 or 15.4 NCAC 02C.0200 lVell Construction Standards and that a
Ifthis is a repair,fill out knoxn well construction informatio,/and�r`plain the nature gl'the copt'tcJ this record has heen provided to the tt•ell owner.
repair under#21 remarks section or on the back oflhis form.
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: SUBMITTAL INSTRUCTIONS',
9.Total well depth below land surface:__ vv (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deptks ifdiJferent('example-3@200'and 2 c@100') construction to the following:
10.Static water level below top of casing:40
( ) Division of Water Resou'rc es,Information Processing Unit,
Ijrvater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6118 (in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of thislform within 30 days of completion of well
12.Well construction method: construction to the followin
(i.e.auger,rotary,cable,direct push,etc.) g'
Division of Water Resources,lunderground 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 Supply&Iniectio i Wells: In addition to sending the form to
the address(es) above, also subrriit lone copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1t2 Lb completion of well construction to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016
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