GW1--03381_Well Construction - GW1_20230515

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONE
FROM .1.0 DESCRIPTION
Well Contractor Name /'G ft. 26 ft. III
2857-A
NC Well Contractor Certification Number 15,OUTER CASL'G for mulu se wells OR LINER if'a
FROM lkable
B &K Well Drilling Inc TO DIAMETER 7HICKNESS MATERIAL
D ft. ft- 61/8 in, SDR-21 PVC
Company Name 16.INNER CASING OR TUBiNG eothertttal closed-loo .
2.Well Construction Permit#: 1°•FROM TO DIAMETER THICKNESS MATERIAL
� `"1 ft. ft.
List all applicable well construction permits Ji.e.UIC,County,State,Variance,et. c�
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural rJMunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft• ft. in.
industrial/Commercial [3Residential Water Supply(shared) .I8.GROUT
Irrigation
EOM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
tt. ft.
Non-Water Supply Well:
Monitoring Recovery ft. ft.
Injection Well: ft, ft.
Aquifer Recharge DGroundwatcr Rcmcdiation 19.SAND/GRAVEL PACK if a Ucable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control tt. tt.
Geothermal(Closed Loop) Tracer 20.DRILLLNG LOG attach additioasl sheets if uecessa
FROM TO UESCRIY'1'ION(color, rdnesx soiVcvck n' e. coin s[ze.etc.)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) ft. ft.
C ft. eft.
ini
4.Date Well(s)Completed. 11 ID#
a.Well Location:.
ft. ft.
acility ID#(if a licable)
Facili /Owner Nain PP ma's r
Physical Address,City,and Zip
21.REMARKS
County Parcel Identification No (PIN) In �;� , ,.,.yrs r. I1A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer' on:
Signature of crtified Well C actor Date
6.Is(are)the well(s)oPermanent or OTemporary
By.signing this fu•m, l herehv cerfijr that the well(s) was(were)c•onsitucted in accordance
7.Is this a repair to an existing well• []Yes or Xda
with 15.4 NC'4C'03C.0100 or 15.4 NCAC 02C.0200 Nell Construction Standards and that a
lfthis is a repair,fill out known well construction informationlain the nature q("the c'opv'of this record has been provideil 10 the vi'e!l axrter.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well dep elow land surface: ✓�� (ft-) 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 3@.100') construction to the following'
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use.•+•• 1617 Mail Service Center,Raleigh,NC 27699-1 61 7
11.Borehole diameter: 6 1/8 _(in.) 24b.For infection 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) JO Method of test- Air Flow 24c.For Water Supply&: Injection 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: 1 112 Lbs completion of well construction to the county health department of the county
where constructed.
Revised 2-22-2016
Form GW-i North Carolina Department of Etrvironmcntal Quality-Division of Water Rcsourccs