GW1--03366_Well Construction - GW1_20230515

WELL CONSTRUCTION RECORD(GW 1)
Int
I.Well Contractor Information: For ernal Use Only:
Robert Teague
Well Contractor Name 14':WATERZfl1RF `: r; f
FROM TO 2857-A DESCRIPTION.
S� ft. �G ft �
NC Well Contractor Certification Number ft cs ft.
!'yl
B& K Well Drilling Inc 15.0 UTTER t;ASING'fUrmul'$as 'welts pR'LIIVER.d °"'fkable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name D ft. J fL Q 6 1/8 in. SOR-21 PVC
2.Well Construction Permit#} r'16t.INNER:CAMGOR:,M]NG ea[ a1e.16s
List all applicable well construction permits(i.e. IC,County. tare.Variance,etc. FROM ft.
DIAMETER TAtCK:NESSMATERIAL
ft. in.
3.Well Use(check well use):
ft. ft. in.
["the
Supply Well: :IT.SCREEN
cultural OMunicipaUPublic FROM TO DIAMETER SLOTSI7E THICKNESS M1IATERIAL
thermal(Heating/Coolin supply) ft. ft. 1O
g PP Y) Residential Water Supply(single)
strial/Commercial Residential Water Supply(shared)
ft ft, m
Irrigation
PP Y(s ;:IB.GROIPT:
ater Supply Well: FROM TO MATERIAL EM1IPLACEMENT METHO 11 D&AMOUNT
ft. it
itoring Recovery
on Well: ft, fL
fer RechargeGroundwater Rcmcdiation ft. ft.
fer Storage and Recovery [3Salinity Barrier SANDlGR:4VELPACIC'da cable
er Test FROM To MATERIAL EMPLACEMENT METHOD
�Stormwater Drainage ft. ft.
imental Technology Subsidence Control
ermal(Closed Loop) Tracer et' ft.
ZQ"DAWLLVG LOG"attach9dd[fia°a1sheets if ne
ermal(Heatin Coolin Retum) Other(ex lain under 4#21 Remarks) FROM TO
DFSCRIPTION(mloq h ft. ft. ness,sot ro ;•r. ,n slrP.etc.)
ft.
4.Date Wel(s)Completed:3~3--�Y�ell Ill##
i 1 fL
5a.Well Location: L
fL
1 fL
Facility/Owner Name 6 ft.
aciliry ifapplicablc) ft. It.
1 ft. r R�
ft. :'=
Physical Address,City,and Zip
ft.
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 7r r J l;y
1Vl ^
(if well field,one lat/long is sufficient)
22.Certific '
N W C'
6.Is(are)the well(s)oPermanent or Tem ora
P ry ignaturo of Certified Well Contra r Datc
7.Is this a repair to an existing well: ]Yes or By.signing this loan,1 herehv,certh'that the well ft)was(were)constructed in accorda cc
n
,Phis is a repair,f!!out known well constructlo�n in
an es Dlain the nature ojtlte it h IS.4 NC.4 d has h 00
repair under#21 remarks section or on the b pro l SA NC,C 02C.0200 00 Well Cmistruction Standards and that a
ack ojthis form. the
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23 Site diagram
use back offth this page prod ide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells You may P g P
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
Formultiple wells list all depths ifdifferent(example-3 rr200'and 2@100� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 40 construction to the following:
Ywarer level is above casing,use"+" (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1/8 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
Air Rota 24b.
12.Well construction method: Rotary For Iniection Wells: In addition to sending the form to the address in 24a
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:
=WATER WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test. Air Flow24c.For Water Sunaly&Injecton Wells; form to
hlor Tabs 1 1/2 Los the address(es) above, also submit One copy of this[form on to swithin 30ending e days of
Amount: completion Of well construction to the!county health department of the county
where constructed.
Form GW-I
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016