GW1--03408_Well Construction - GW1_20230515

Font Foie ' s
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14:WATER=zoNEs
Well Contractor Name FROM TO DESCRIPTION
2857-A
ft. ft.
NC Well Contractor Certification Number 15i'OUTER-CASING for' It
wens),'OR`LINER'if a lieable . ,
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft' I't. 61/8 in. I SDR-21 PVC
_
16:INNERCASING:ORTUBING "`eotherinalclosed-loo
-2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
t7:rSCREEN. ;:
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
Industrial/Commercial [31tesidential Water Supply(shared) y it GROUT..;
)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Remediation _
%19::SANDiGRAVEL.PACK rfa 7icable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT UETHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 7TO..DRILLLNG LOG'attach additional sheets if oecessa" ::.
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,haconess,soiilfmckth%,pegminsfze etc.
ft.
4.Date Well(s)Completed`' 1A_ —�!e111D# ft. ft.
ft. ft.
Sa.Well Location: )d ! C dr�n A ft. ft
(.�/•�
Facility/Owner Name Facility ID#(if applicable) ft. ft. 4�
ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN) LJWl
�
Care} tJC
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: In "rr�r..-.
(if well field,one Iat/long is sufficient) 22.Certificati
N W 41 oZ
6.is(are)the well(s)oPermanent or Temporary ignature of Certified Well Contrac or Date
By signing this form,l hereby certify that the well(s)Bras(were)constructed in accordance
7.Is this a repair to an existing well: Yes on o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ijthis is a repair,fill out known well construction injnrmalion n .plain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis 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 GWA is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ASUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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 c@200'art 100') construction to the following:
10..Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
Ijwater 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
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.)
bivision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: Air Flow 24c. For Water Suualy&Injecting Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: t 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