GW1--03401_Well Construction - GW1_20230515

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague a4:WATER:ZONES:
Well Contractor Name FROM To DESCRIPTION
2857-A
S d ft. C ft.
ft. ft. I
NC Well Contractor Certification Number
15.OUTER CASING for ti.:ased wells OR'LINER:H a lieible
B &K Well Drilling Inc FROM TO DIAMETER THICKNESSI MATERIAL
0 fL ft. g 1/8 j to SDR-21 PVC
Company Name
16'.INNER CASINGORTUBING"eotbermelclosed-ltiD
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2.Well Construction Permit#y L �U I?I — ISI 1, t FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Wa @
ter Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SI7E THICKNESS MATERIAL
Agricultural [3Municipal/Public ft ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT `.
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Rcmcdiation
Aquifer Storage and Recovery `9Satini Barrier 19.SAP-DIGRAVEL PACK'ifa Ilcable ".,
!J' FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal Closed Loop)P) Tracer 11:DRILLL9G I.DG attach sdditioual sheets if aecessa " - a
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) IFROM TO DESCRIPTION(color,hardne soil/mck type, rain size.etc.
ell\ ft. ft.
4.Date Weil(s)Completed:—3 Well ID# ft. ft.
5a.Well Locati n: ` , n ft ft.
Fyacility/OwncrName `n��111>��` Facility ID#(ifapplicablc) ft.
V ft
) Ci!q L-I—L� 0 yn ft. ft.
Physical Address,City,and Zip
21 �...
.� ....
.REMARKS
County Parcel Identification No.(PIN)
VI �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certificati
N w 3`a s- D 3
6.Is(are)the well(s)oPermanent or Temporary ignature ofCcrtificd l Contractor Etc
By signing this./'arm,1 herebv cent Ji'that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or NO with 15.4 NC'AC 02C.0100 or 15A N,CAC 02C.0200 Well Construction Standards and that a
/'this is a repair,fill out known well construction informal.,a explain the nature of 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
G SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3«200'and 2 a 100') construction to the following:
10.Static water level below top of casing:40 (ft.
Division of Water Resources,Information Processing Unit,
{f water level is above casing,use••+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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) Method of test: Air Flow i24c.For Water Supply&Injection;Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Los 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.
Form GW-1 North Carolina Department of Environmental Qualiry-Division of Watcr Resources, Revised 2-22-2016 /�-