GW1--03404_Well Construction - GW1_20230515

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 7
1.Well Contractor Information:
Robert Teague �a:WATER'ZflNE5.:" I•:
Well Contractor Name FROM TO DESCRIPTION
2857-A loft• fr.
ft ft. i
NC Well Contractor Certification Number
'15'OUPER CAS'I1VG for multc8sed wells OR LINER:
IF
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
p ft ft. 8 t/il rn• SD
Company Name R-21 PVC
1CJNNEWCXSMG:ORTUBING eetherinal elaseil;ioo
2.Well Construction Permit#: r/ lJd� J 1 �z�L`! FROM TO DIAMETER I 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.
Water Supply Well:
17:-SCREEN.
FROM TO DIAMETER SLOTSI7.E THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. fr. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft fr, in.
Industrial/Commercial 13Residential Water Supply(shared)
;:18:GROUT .... . ..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
Injection Well:.
ft.
Aquifer Recharge Groundwater Rcmcdiation ft
'�19:SANDi.GRAVEL;PACK'da 'cable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Closed Loop) Subsidence Control ft. ft.
Geothermal
( p) Tracer 20:DRILLLVG11.06 attach 9dditionsislieetsidnec-ssacK. ... ..a
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To I DESCRIPTION(color,ha ness.milfmck ry a rain size,etc)
ft. (-J ft.
4.Date Well l-�s)Completed� q- Well 1D# ft ft.
5a.Well� Locati'oSn: ft. ft.nA I e` ft. fL
Facility/OwncrName Facility iD#(if applicable) ft. ft a �'
as dio,
Physi I Address, ily,and Zip i~ ft. ft
NAM 1.
CC*rXWba ;it:.R$MARKS.
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' c on:
N w
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Wcll Co ractor' Date
By signing this firm.i herehv certyJ that the cell ft)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes o No with I.5.4 NCAC 02C.0100 or 15A NCAC•02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction infarmatinn a lain the native of the copy of this record has been provided to the well owner.
repair under#2I 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total we�dep below land surface: 0 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@I00') 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 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection 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&Iniection 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 constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016