GW1--03403_Well Construction - GW1_20230515

Fnn1 Form
WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER-ZONES.
Well Contractor Name FROM To DESCRIPTION
2857-A
1 a. g• ft.
ft ft. '
NC Well Contractor Certification Number
15.OUTER CASING for.multiased wells OR`LINER if a livable
B & K Well Drilling Inc FROM To
DIAMETER THICKNESS MATERIAL
D ft ft. 61/8 1°' SDR-21 PVC
Company Name
—1 r:16.•INNER CASING.OR I tJBING eotheirmal cltiaed-l' =.
2.Well Construction Permit#: 1�(� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. IL
in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared)
PP y 18rGRUVI?
Geothermal
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Remcdiation
19.SAND/GRAVEL PACK if a cable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. tt.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if d cissil
Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) I FROM TO DESCRIPTION(color,hardness,son,.ck tv e, rain size,etc.)
ft. ft.
4.Date Well(s)Completed: y .23 Well 1D# ft. "-
Sa.Well Loc 'on: c --ft ft.
ft ft
Faaccility/Owner`Name Facility ID#(if applicable) ft. ft
SG S LnYl� �C✓ L� ft. rt. 0`4 -�r
Physical Address,City,and Zip
ft. ft. a e .
21.REKkRKS
e � —
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^ ; ""NZ
(if well field,one lat/long is sufficient) 22.Cer
N "' oZ4 ,23
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Cont4ctor Datc
�,, Hy signing ihis loan.i hereby certifc that the uvil(.$)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes o, No with 15,4 NC'AC 02C.0100 or 15,4.NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information an plain the nature of the copy ofihis 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:
S.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:
S SUBMITTAL INSTRUCTIONS
9.Total well dep below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi ffierent(example-3«200'and 2 rCi/00J 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 infection 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
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) Ln Method of test: Air Flow 24c.For Water Supply& Isliectlon Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs 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 constnicted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016