GW1--03372_Well Construction - GW1_20230515

WELL CONSTRUCTION RECORD GW-1
l; nForrn
I.Well Contractor Information: For Internal Use Only:
Robert Teague
Well Contractor Name r i'4`WATER�ZOIVES - �.c�_,�,r
2857-A FROM ft. TO DESCRIPTION
ft. i
NC Well Contractor Certification Number ft ft. I I
B &K Well Drilling Inc sornERCSING foe.
FROM TO mold cased'velTs;'QR:LINEIt'$g'Geable �.
Company Name DIAMETER THICKNESS MATERIAL
0 ft• ft.
++``�,, 7 6 1/8 in. SDR 21 PVC
2•Well Construction Permit#: 14V -21
/� ]6;INNERCA OR.TiTgING eotger l`cl luu
List a!1 applicable well construction permits(i e.UlC,Comity,State,Variance,etc.) FROM TO DIAM TER - un
E THICKNESS MATERIAL
3.Well Use(check well use): ft ft. in.
Water Supply Well: ft. ft. in.
AgriculturalFROM
IlMunicipaUPublic DIAMETER r SLOT SIZE n. THICKNESS AfATER1AL
Geothermal(Heating/Coolin Supply) it rr R
g PP Y) OResidential Water Supply(single)
Industrial/Commercial Residential Water supply(shared) ft ft to
hri ation PP y( CA-
NOR-Water Supply Well: FROM
MATERIAL EMPLACEMENT METHOD&AMOUNT`
Monitoring rt• ft
Injection Well: Recovery
ft. ft.
Aquifer Recharge Groundwater Remcdiation ft. ft.
Aquifer Storage and Recovery Salinity Barrier
SANll/GR4YEL.PACI( tf a '' ca61e
'Aquifer Test FROM r0
Experimental Technology Stormwater Drainage MATERIAL EMPLACEMENT METHODz
rt• ft.
Subsidence Control
Geothermal(Heatin Cooling Return)Geothermal(Closed Loop) Tracer ft• ft.
a'ZO::DRILI 1NGi:Return) Other(explain under#21 Remarks) lE}G attachaddtdauiiLsheets ifae�s _.FROM TO DESCRIPTION(color, rdoess so' rock - ��
ft. ft• type, in size,etc.)
4.Date Well(s)Completed
WellID# ft. ft.
Sa.Well Location:
it. f
(�J ft. L
Faedtty/pwner Name
FacilitylD_#Cif applicable) ft. ft.
11�Z.r, �y 1� to ft.
PhysicaTAddress Cny and Zip ft.
/ ft. ft
C::: 16061.'1- zi.•R1Rl�s r I t-�
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certi£ on: If1sS3ir:."G:
N Pr"•r_2��T�,rq Urrsi
W Ck�.i21�s
6.Is(are)the well(s) Permanent or Temporary ignature of certified Wf} Contmctor —
Date
7.Is this a repair to an existing well: Yes or By.signing[his jarm, !hereby certify that!!re rve!((s)was(net•e)constructed in accordance
Ij[his is a repair,fill out known well conslruc[io jormarioa and'explain the nature ojthe OPy jthwith 15,4��ecord has b e provided,,h 02e!�%00(Yell Construction Standards and that a
repair under#21 remarks section or on the back of this form.
3.
agram or
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 2 o may use he back of this llto provide additional well site details or well
Construction,only 1 G1 -I is needed. Indicate TOTAL NUMBER of wells You may page P
drilled: construction details. You may also attach additional pages ifnecessary.
9.Total well dept below land surface: V S SUBMITTAL INSTRUCTIONS
For multiple wells list a!1 depths/fdi$erenr(esample-3@200'mrd 2@I00) (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:
Ywater level is above casing,use +" (ftJ Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
12.Well construction method: ry above, r Insubmin onelco In addition to sending the form to the address in 24a
Air Rota
(i.e.auger,rotary,cable,direct push,etc.) constructionpy of this form within 30 days of completion of well
to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm) j Method of test: Air Flow 1636 Mail Service Center,Raleigh,NC 27699-1636
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24.For Water Supply R:Injection Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs 1 112 Lbs the address(es) above, also submit one copy of this form within 30 days of
Amount: 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
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Revised 2-22-2016
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