GW1--03397_Well Construction - GW1_20230515

�wWELL CONSTRUCTION RECORD GW-1 n zM'f'ritt#Fcm -
For Internal Use Oly:
I.Well Contractor Information:
Robert Teague
Well Contractor Name TA:WATER'ZUIVES :...
FROM TO DESCRIPTION
2857-A :5 f U s ft.
NC Well Contractor Certification Number ft ft.
B &K Well Drilling Inc Is OUTER.GASING'far multi-cased welts tOR7iINLrRi It cable
FROM TO DIAMETER THICKNESS MATERIAL '•
Company Name 0 ft. ft.
6118 tn• SDR-21 PVC
2.Well Construction Permit#: &C) 16;AVNER.Ci�ING.OR TUSING; ,the ival FROM TO DIAMETER THICKNESS ESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, ..
Yarianre,etc.) ft. It.
3.Well Use(check well use): rt.
ft. in.
Water Supply Well: 17srSCREEN.
Agricultural �MunicipaUPublic FROM TO DIAMETER SLOTSIZ-E THICKNESS MATERIAL
Geothermal(Heating/Cooling ^
I ft. ft- in.
Supply)y) Residential Water Supply(single)
IndustriaUCommercial ft. ft. in.
Residential Water Supply(shazed)
Irrigation :IS GRODT
Nn-Water Supply Well: FROM TO MATERIAL EM1IPLACEMENT METHOD&4M 1. OUNT
Monitori ft. ft.
ring Recovery
ft
In o
jection Well: • ft.
Aquifer Recharge [3Groundwater Remediation ft. ft
Aquifer Storage and Recovery oSalinity Barrier 19:`SANDIGRAYEI°PCIC'rf:a cable
Aquifer Test FROM TO MATERIAL EMPLACEMENTAfETHOD oStormwater Drainage ft. ft.
Experimental Technology Subsidence Control
ft. ft
Geothermal(Closed Loop) Tracer
20'DRILLLYG t(}G�attach 9tldttioiisi sheet§'if:ne _
Geothermal(Heatin Coolie Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiVrock h e rains
ft. ft.
4.Date Well(s)Completed:� I- We11ID# ft. t•
5a.Well Location: ft ft.
.�Q11/ ft. ft.
Facility/Owner Namc '
Facility ID#(if applicable) ft ft.
3L
l r ' ft. fL is ► //
Physical Address,City.and Zip FO ft' ft MAY b L
�. p 21 REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: { L
(ifwell field,one lat/long is sufficient)
22.Certification:
N �,
6.Is(are)the well(s)oPermanent or oTemporary Si /2,
aturc of Certified Well Con ctor
Date
BP signing this farm,I herehv certify-that the weQ(s)was(were)constructed in accotdance
7.Is this a repair to an existing well: Yes or 0 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction information rs plain the nature o f the copy of this 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/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-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: A) 24a
For multiple wells list all depths ifeliferent(example-3@ and 2@l00� . For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40 ,
/f water level is above casing,use"+^ (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: (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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
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
13b.Disinfection type:
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
Amount. 1 1/2 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