GW1--03368_Well Construction - GW1_20230515

PCIntForm .
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague .14..WATER_ZONES
Well Contractor Name FROM TO DESCRIPTION
2857-A ( fc. ft.
NC Well Contractor Certification Number 6
15,'OUTER'CASING formulti-cased wells OR'LINER'ifa Iicable
B &K Well Drilling Inc FROM TU DIAMETER THICKNESS MATERIAL
Company Name 0 ft ft. 6 1/8 in. SDR-21 PVC
I( 'r� 7 �/� �+ S6cIANERGASI OR TUBING eothermsiclosed-1
2.Well Construction Permit#j��W�}J- no -1 FROM TO DIAMETER THICKNESS 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: 17.SCREEN ...
FROM TO DIAMETER SLOTSVE THICKNESS MATER[AL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OX Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)PP Y ) IS.GROUT
..
Geothermal
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. It.
Monitoring ORecovery ft. ft.
Injection Well:
ft. fL
Aquifer Recharge
..Groundwater Rcmcdiation
19.SAND/GRAVECPACK If applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach Additional sheets if necesas: 'i
Geothermal(Heating/Cooling Return) r3 Other(explain under#21 Remarks) FROM To DESCRIPTION(col ,hardness.soiUmek type in size.etc.)
ft. ft.
4.Date Well(s)Completed-3—. - S5 3 Well ID# tNft 2 rj ft. hAF
5a.Well Location: V ft. ft.
ft ft
Facility/Owner Name l Facility ID#(if applicable) ft. ft
;17
' L
Physical Address,Ci ,and Zip ft. ft.
n
Li h �n� icy iv 21.REMARKS
County Parcel Identification No.(PIN) 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 3� s--
ARZZ: ��
6.Is(are)the well(s)oPermanent or 13Temporary Signature of Certified Wcll on c r Datc
Ad
By signing this form,I herebv cerfiji that rite well(.$)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or o with 15A NCAC'02C.0100 or I5A NCAC 02C.0200 lVellCnnstructionStandardsandthata
lfthis is a repair,fill out knoxn well construction information\\�d fain the nature of the copy of this record has been provided to the well ox ter
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well dep9 below land surface: -/ 7 (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 m 0 'and 2 t@100') construction to the following: '
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
!f water level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
246.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 this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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 Suouhv& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1!2 Lbs completion of well construction to the county health department of the county
where constructed.
y' Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016