GW1--03405_Well Construction - GW1_20230515

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague :14.WATERZONEs.;
Well Contractor Name FROM TO I DESCRIPTION
2857-A 6 It. S ft. GOO
ft. ft.
NC Well Contractor Certification Number
15:0.UTER CASING for mattizcased wells':t7It G1NER'>f a"ticatile
B &K Well Drilling Inc FROM T DIAMETER THICKNESS MATERIAL `
Company Name D ft. ft. 6 1/8 in. SDR-21 PVC
—' G I 15'INNEIt:CASING OR TUBING+' theriiial closed ltiu
2.Well Construction Permit#: 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.
Water Supply Well: 17i:Sf REEK;;.
Agricultural []MunicipaUPublic
FROM To DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) ft.
Industrial/CommeIcial Residential Water Supply(shared)
18c GROUT
Irrigation FROM TO MATERIAL EMPLACEMEVTMETHOD&.�M110UNT
Non-Water Supply Well: ft. FL
Monitoring Recovery It,
ft
Injection Well: ; �T ,•;
ft.Aquifer Recharge oGroundwatcr Remcdiation ft 7 n
Aquifer Storage and Recovery Salini Barrier 19.'SANDIGRAVEI PICK>fa `licable :,-
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage ft ft.
Experimental Technology [3 Subsidence Control ft. ft. r
Geothermal(Closed Loop) Tracer
ZO:bRILLLVG�i:OG"aftach'atldtfiunslsheetsif'ae'
Geothermal(Heating/CoolingReturn) rl Other(explain under#21 Remarks) FROM TO DESCRIPTION(mlor,h ess,s WU L,h e rain size.etc)
-
�1 1
4.Date Well(s)Completed - d- Well ID# ft. Z G
j5�a..�Well
L.,00cca ion- ft. ft.
t-�- t cIt- ft ft
Facility/OwnerNarhe Facility 1D#(ifapplicable) fL M
{
d5 J
Physical Address,City,ana Zip ft. ft.
21:REM IRKS
. .............................................
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.Certi lion:
N W 1 7 a
�
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Con •tor Date
By signing this fwm.I herelGv certify that the w•ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Ryes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction injnrmation a plain the nature of the copy ofthis 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 OW-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: 1 S, M-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdif]erent(example- a Z00'and 1@100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'•+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (in.)
246.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) V� Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2 Lbs 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