GW1-2023-01919_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD GW-1 >PrittFai
For internal Use On �� '�•`"°''"• '`�""''
I.Well Contractor Information: ly:
Robert Teague
Wcll Contractor Name 14fR'ATERZONES:r. f:F: _.N. �•, 7.
FROM' TO DESCRIPTION
2857-A :...::
7 Oft $ ft. d
NC Well Contractor Certification Number s ft. L� g,
B&K Well Drilling Inc 1&-OUTERCASING tor:multi cas ' s OR LIIVER if' ''Itcable FROM TO DIAMETER THICKNESS MATERIAL
Company Name p ft. 5 ft.
61/8 in. SDR-21 PVC
2-Well Construction Permit#: 15:INNER CASING OR.T J-HIN eoiherinal ctosetldoo
LLw all applicable well construction permits(i.e.UIC,County,Stale,1 arianre,etc.) FROM ft TO DIAMETER THICKNESS MATERIAL
in.
3.Well Use(check well use):
ft. ft. in.
Water Snpply Well: 17:SCREEN :'':
Agricultural IDMUnicipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Geothermal(Heating/Cooling Coolie Supply) ft ft• m.
� g pp y) Residential Water Supply(single)
IndustriaUCommercial ft ft in.
Residential Water Supply(shared)
Irri ation
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
ft. fL
Monitoring Recovery
Injection Well:
Aquifer Recharge E)Groundwatcr Rcmcdiation ft. ft.
Aquifer Storage and Recovery OSalinity Barrier 39.SAND/GRAVEL.PACK da'
Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD�Stormwater Drainage ft. fL
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer ft it.
20:.DRILLING LOG .ttach'additioitaisheets ita' " '
Geothermal(Heatin Coolie Return) Other(explain under#21 Remarks) FROM I O 4.,.,.....
UFSCRIP7'ION(color.h ness,saiVrock e, rein size,eta)
Jr. fr
4.Date Well(s)Completed: l���ell ID#
t. a
Sa.Well Location: fi
fit. fL
Factuy/Owner Name
Facility IDb(ifapplicablc) -^--
.770
U fit. ft. Q
Physical Address,City,and Zip
fit It.
21:REMARKS"""'
I
95.Yn
Parcel Identification No.(PIN) IntFixiarr:r7D� c�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l(ifwell field.one lat/long is sufficient)
22.Certification:—�
N W
6.Is(are)the well(s) Permanent or oTempora Signature ofCcrti tcd WcZ,Wactor
Date
7.Is this a repair to an existing well: OYes or 4v signing this form,1 hereby cerriJp thai the wells)was(were)consnvcted in accordance
Ifthis is a repair,fill out known well construction information and lain the na[ur a gjthe cop"ity of re urd'has-been provided N to CI 02C. 200 Well Construction Standards and that a
repair under 121 remarks section or on the back ojthis form.
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same 23.Site diagram or additional well'aetails:
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
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface:�S SUBMITTAL INSTRUCTIONS
For multiple wells list all depths ifdijjerent/exam le-3 W-) 24a. For All Wells: Submit this form within 30 days of completion of well
p @_no•atdz@!oo') following:
10.Static water level below top of casing:40 construction to the follow ,
Ifwarer level is above casing,use'•+,, (ft-) Division of Water Resources i Information Processing Unit,
11.Borehole diameter.
6 1/8 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Iniecton Wells: In additi lit 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
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Unde ground Injection Control Program,
` 1636 Mail Service Cen ier;Raleigh,NC 27699-1636
13a.Yield(gpm)\ b� Method of test: Air Flow 2 4e.For Water Supply&lnlection Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs Amount' 1 1/2 Lbs the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Watcr Resource
Revised 2-22-2016
I