GW1-2023-01917_Well Construction - GW1_20230222

``.'ELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:i
I.Well Contractor Information:
Robert Teague I
l �
14.WATER ZONES
Well Contractor Name FROM TO IDESCRIP'I'ION
2857-A eft. ft.
ft, ft.
NC Well Contractor Certification Number
1'.OUTER CASING for multi-cased wells OR LINER if a ))cable
B&K Well Drilling Inc FRUhf TU DIAMETER THICKNESS MATERIAL
Company Name 0 ft- It. ,61/8 in. SDR-21 PVC
16.INNER CASING OR TUBING eothermat close
d-too
2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicahle well construction permits(i.e.U1C,County.State.P4riance,etc.) ft• ft. in.
3.Well Use(check well use):
EAgricultural
y Well: 17.SCREEN.-
FROM '.
TO DIAMETER SLOT SIZE THICKNESS •MATERIA[3Municipal/Public in.
(Heating/Cooling Supply) Residential Water Supply(single)
ft ft. in.
ommercial Residential Water Supply(shared) '18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL f
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge oGroundwater Remcdiation ft, ft• d
Aquifer 1%SAND/GRAVEL PACK If a livable
Recovery [3SalinityBarrier FROM TO MATERIAL THOD
EMPLACEM1fENTM1fE
Aquifer Storage and Recove Test [3Stormwater Drainage ft• ft.
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach addltiooal sheets if necessa
Geothermal(Hearin Coolin Return) ]Other(explain under t21 Remarks) FROM To DFSCRWIION(color,ha ess,sailtrnck ts e, rain size,etc.)
c ft ft.
4.Date Well(s)Completed: /_ a— ell ID# ft. ft.
5.
5a.Well Location: t. ' ft.
ft ft
`Factliry/OwncrNamc Facility lD#(ifapplicablc) ft. ft.
Physical Adorers,City,and Zip ft. ft. FEE) 2 .r 2023
i7U Y lke .21.REMARKS.'
oun�ty Parcel Identification No.(PIN) I DwQiB
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field.one lat/long is sufficient) 22.Certifica I
N
6.Is(are)the well(s)oPermanent or 13Temporary 91gnatunc ofCcrificd Wcll Co ctor Date
4v signing this form,l herebv cerlJy that the nell(s)was(were)consnucted in accordance
7.Is this a repair to an existing well: []Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!'this&a repair,fill out known well construction informadona4des 'sin the nature afthc copy ofthis record has been provided to the well owner.
repair under V 1 remarks section or on the back o'this 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 1 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 de_below Land surface: OS' -- (ft) 24a. For Ail Wells: Submit',this fo m within 30 days of completion of well
Far mulrple wells list all depths ifdierent(example-3@200'and
construction to the following:
10.Static water level below to of easing:40 I
I'warer level is above casing use*p" (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above,also submit one copy of tliis form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push.etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resourcel,underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Air Flow 24c.For Water SuDDIv&InieI tiIon Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs Amount 11/zLbs the address(es) above• also suliimit one copy, of this form within 30 days of .
completion of well construction tq' the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Em ircnmental Quality-Division of Watcr Rcsourcs
Revised 2-22-2016