GW1--03370_Well Construction - GW1_20230515

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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 50 fc. fp fr. y i
ft. ft. i I
NC Well Contractor Certification Number
15.OUTER CASING for malticasid wells ORLINER if a 'ticahle .. ,
B &.K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ft. 6118 in. I SDR-21 PVC
Company Name
16.INNER CASING.OR TIJBiNG: eothermal chised-1 ' •
•2.Well Construction Permit#• �'�1+u. � - �� FROM TO DIAMETER THICKNES5 MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Varianre,etc.) ft. ft. in,
3.Well Use(check well use): ft. ft• in.
Water Supply Well:
11 SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural 13MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial [3Residential Water Supply(shared) Ig.GROUT. .
Geothermal
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft.
Injection Well:
Aquifer Recharge DGroundwatcr Rcmcdiation ft. fr.
19.SAADlGRAVEG`PACLC Cifa Iicable
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.DRILLUNG'LOG'attach additional sheets if aims
FROM TO DESCRIPTION(color,hard em soil/rock t,• e, ram size,etc.)
Geothermal(Heating/Cooling Conlin Return) Other(explain under#21 Remarks) ft. ft.
1 /
4.Date Well(s)Completed:3 -I %-�)L I1W# ft. Ft. ! l )
5a.Well Location: ft. ft.
t?„>r Li�� ft. ft ,
FacilityROOwn`er�Name' j^ ,/'n^ Facility
JID#(if applicable) ft ft.
.I lJ 1 C ' i a Y✓ `C'm L 1/ ft. fL i %., :3 �1 ti ?
Physical Address,City,and Zip ft. ft. MAY 1 5, 3
L�1f C'�1��G Y\ zi.REMARKS:
County Parcel Identification No.(PIN) nf-f;;I 4�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifu.
N W
6.Is(are)the well(s)oPermanent or Temporary Signature of Ccrdfi&We'll Contractor Date
By signing this form,1 herebY c•ertiy. that the well(s)was(were)c•onsn•ucled in accordance
7.Is this a repair to an existing well's or nNo with 15A NC'AC'02C.0100 or 15.4 NCAC 02C.0100 Well Construction Standards and that a
Ijlhts is a repair,fill out known well construe on
to oration and explain the nature of the copy ojthis record has been provided tit the well owner.
repair under#21 remarks section or on rite ck ojthis 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,oplg1 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 depth below land surface: C�" (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-31t 200'a»d 2 t@t 100') construction to the following:
10.Static water level below to of casing:40 p g: (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
Air Rotary 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.)
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& 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 1t2 Lbs 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 Water Resources Revised 2-22-2016