GW1-2023-01921_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague4:=WATER=zI) R l i,g
Well Contractor Name FROM TO I DESCRIP ION
2857-A
ft. ft. `•
NC Well Contractor Certification Numbers
6IS:,:OUTER'CASING"for,mtilti=cased•'wells OR,'EINER it
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. /1 ft. g 1/8 „ In' SDR-21 PVC
Company Name t J�
:y6INNERtCASING UR,TUBING ebthet•mai closed=ldo' `��,x �-;�:.�: ;�;:"��:a;Y�,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I 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: 17SCREEN;.�
,...;;,:.;.„::<`-a'":..::::a.-,err.t5;a<,4¢r,=ass'. «a,,^.<a�.,k::Eati,•::1.i':
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural I []Municipal/Public ft. ft. in.
u
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. hi.
Industrial/Commercial 1
�Resldenhal Water Supply(shared) _
�s
fit �n•a<'s,_ ' ,->_��,:•
Irri ation FROM TO MATERIAL {PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EIRecovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery SalinityBarrier �::SANDlCR 4YEL PACK f•a "liaahle;,; _:: a"_ ,a:,_,'°,: ;;,;=`:x"`,=jr=34;
FROM TO MATERIAL I EMPLACEMENT METHOD -
Aquifer Test OStormwater Drainage
Experimental Technology 0Subsidence Control
•
Geothermal(Closed Loop) 13Tracer -,,20.,DRILLING,,"EOG"attach additi6fi' `"sheets iLiie6essar ?111,10"`"'"""
FROM - TO DESCRIPTION(color,h ness,soil/rock e, rain size,etc.)
Geotheimal(Heating/Cooling Return) Other(explain under#21 Remarks) ft.
4.Date Well(s)Completed:) Well ID#
ft. ft.
Sa.Well Location: g r
e
ft. ft. .k ZZ ' .t Ell 6,E° 4.�~
Facility/Ow me ner a Facility Ip#(if ap licabl ft.
ft. I x
IC L-) L J A
1 . ft. 3
P sical Address,City,and Zip ft. ft. �' {Ii�ivi Ei'e.3w^l �fL`:;oy r 3 U n..l
%
County Parcel Identification No.(PIN) I�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: II
i
({£well field,one fat/long is sufficient) 22. )rti.In-.
NW ��-
6.Is(are)the well(s)oPermanent or Temporary Sign tune ofCertifed Well Cont ctor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes 0r o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Iflhis is a repair,fill out known well construclion information lain the nature ofthe copy ofthis record has been provided to•'the well owner.
repair under#21 remarks section or on the back of 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 is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages if necessary.
(, I
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 V S' (ft-) 24a. For All Wells: Submit this, form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� Construction t0 the following: i'
10.Static water level below to 40 I
p of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:,6 /$ (in.) 24b.For Infection Wells: In addition to sending.the form to the address in 24a
Air Rotas/ 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.) , i
Division of Water Resources,Underground 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&Iniectll n Wells: In addition to sending the form to
Chlor Tabs 1 1l2 Lbs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to,tie county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources{ Revised 2-22-2016
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