GW1-2023-01916_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague .14..WATERZONES_.-`-
Well Contractor Name FROM TO DESCRIPTION
2857-A 4boft_ (434cfl- I i men
5 3-0 ft.
NC Well Contractor Certification Number -5 41
15:-OUTER CASING(for-could-cased wellOOLt,L ER FLN ifaligilLable)
IC 4
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS
MATERIAL
Company Name 0 ft' ft. 6 1/6 in. I SDR-21 PVC
J&'INNER'CASINGORTUBING(ge6;6thir-alclosed4l000)'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
��List all applicable well construction permils(i.e.UIC,County,State.Variance,etc.) ft. ft. L in.
3.Well Use(check well use): v ft. ft. in.
Water Supply Well: 'A7.SCREENiI:'1
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. ft. in.
th Geoermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) ft,
-18.-GROUT,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
:)Monitoring 0 Recovery ft. ft.
Injection Well: ft. ft.
3Aquifpr Recharge DGroundwatcr Reinediation K Ordiiiptleible)49.SANDIGRAVEL-PAC
3Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT.CEMENT-METH.OD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20..DRILLiNGtiOG(attachadditi6i4d sheets ifneceisat4
FRONT DFSCRIPTIQN(color.hardne5s.jbillrock tvpe,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
'AWell ID# ft. 75­f, r If-
4.Date Well(s)Completed: 5-3%0
S(W45a.Well Location:
Facility/0cr Nam 4 Facility ID#(ifapplicablc) ft. ft.
ft. r
C_ t-- V
yl 4-Xe'
Physical Address,City,and Zip ft. ft.' L
.21.RENIARK9'-
County Parcel Identification No.(PIN) Q,."-'NV2'20 Uri!l
QRI-OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22,Pirtil'i ati
N W f,�
U)JAaAM-A-
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well ntractor Date
4y signing This form,I herebv certijj*Thal the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: � uies or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200{Yell Construction Standards and that a
I
If this is a repair,fill out known well construction 'n 'lon . lain the nature ofthe copy of this record has been provided ti�the well ou-ner.
- 1p
repair tinder#21 remarks section or on the back qf1hisform.
; 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 pag!e to provide additional well site details or well
construction details. You may also additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells o a i !
drilled:_4 SUBMITTAL INSTRUCTIONS
P
9.Total well dept"elow land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(arample-3@200'and 2&00') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Reso 1,or ces,Information Processing Unit,
lfwater level is above casing,use'*+" 1617 Mail Service Len'ter,Raleigh,NC 27699-1617
1, 1
11.Borehole diameter: 6 1/8 (in-) 24b.For Injection Wells: In additibil 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: 11
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,!Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Sul3ply&liflect[ioh Wells: In addition to sending the form to
Chlor Tabs 1 112 Lbs the address(es) above, also subniitt�o.ne copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division ofWatcr Rcsourcc-1 Revised 2-22-2016