GW1--03378_Well Construction - GW1_20230515

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague
14:.WATERZONES .:.`
Well Contractor Name FROM To DESCRIPTION
2857-A S aft. l�� ft.
NC Well Contractor Certification Number
15.'OUTER CASING foiDI
ti.. dedwens OR LINER'if'u'It cable
B &K Well Drilling Inc FROM TU AMETER I THICKNESS iV1ATERIAL
D ft. ft. 6118 in. SOR-21 PVC
.Company Name .
c ,", FROM
WNER CASING:ORTUBIAM eothermel clICKNES
2.Well Construction Permit#:- elf-A" Ut� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17..SCREEN
ater Supply Well: -
FROM TO DIAMETER SLOTSIZE THICKN&SS MATERIAL
Agricultural [3MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
IndustriaUCotmnercial Residential Water Supply hared
PP Y(shared) '::18:GR0UT• ..,
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery k. fL
Injection Well:
ft. ft.
Aquifer Recharge [)Groundwater Remcdiation
19,SAA�lGRAVEL'PAC[C da 'cable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStorrnwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLLNG LOG'attach Additional sheets if necessa '
Geothermal(Heating/Cooling Return) 00ther(explain under r21 Remarks) FROM To DESCRIPTION(color,h2i3iness.soillrock type, rain size,eta)
ft. ft.
4.Date Well(s)Completed: 4--!)3 Well LD# ft ft. c'
5a.Well Location: ft. ft.
Facilityy/OwncrName Facility lD#(if applicable)
I ft © ft
Physical Address,City,and Zip ft. ft.
d a....,6 ...:...,!
o� 21.REMARKS ,�
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.Cert' J y~
N w
6.Is(are)the well(s)oPermanent or [3Temporary gnature of Certified Well cAtractor Date
By signing this!or•m.1 hereby certiy$that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No rs•idr 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/'this is a repair,fill out known well construction information and o plain the nanny Ufthe 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/DPTt 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-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� i (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 ft.
( ) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For Injection 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 Supply&Injection Wells: In addition to sending the form to
ChlorTabs 11/2Lbs the address(es) above, also submit one copy- of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. I I
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016