GW1--03525_Well Construction - GW1_20230519

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague 14.-WATER.
Well Contractor Name FROM TO DESCRIPTION
ft. S ft.
2857-A C�'•-
ft
NC Well Contractor Certification Number ft
-15.:O1LITERtCASING.for:i lttl­casedtiells::URLINER:if 61eiM
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft "' 61/8 In. SOR-21 I PVC
16::INNER'.GASING OR: INIG V Z:...•.;`: _.
2.Well Construction Permit#:©t' ' b i�LI FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.Cottnry•,State,Variance,etc.)
ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: =10:;SCREEN:-
FROM TO DIAMETER SLOT SIZE T THICKNESS MATERIAL
Agricultu al 13Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft ft. in.
Industrial/Commercial OResidential Water Supply(shared)
a,, GRoUT,::::. '.:
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring Recovery ft. ft
Injection Well: ft. ft '^ •(^ i.`> ,ice'+
Aquifer Recharge DGroundwater Remcdiation ^-
19.SAND/GRAVEL-PACK rf.a cable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPIS GE ENT•t THOD
Aquifer Test DStormwater Drainaee
ft. ft. u' L U23
Experimental Technology Subsidence Control ft. ft. n,�,;: -ti%�.� �f^^ hT�l; .;
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additi6uslshietsif
FROM TO DESCRIPTION(color,hardness.soiVrock type. in size,etc.)
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: Well ID# ft' ft. '
Sa.Well
Location-* orb 6 ftC�CEN :iA ILL
ALft. fL
U N N\;:mot z— ' I •' l�A fr ft
Fac w ility/0ncr Nam. Facility IDO(if applicable)
ft. ft.
//P••hysical Address,City.and Zip r,trrl,0 55 � \f C-Ao - ft. ft
t:..t A W �'CJ Z1::RENI4RKS :.:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22.C�* -
N W
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Con or Date
By.signing this form.I hereby certify that the well(,)was(were),constructed in accordance
7.Is this a repair to an existing well: [3Yes or No with 15.4.NC4C 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair•fill out known well construction informa ion an rplam the native 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 G,yJ-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: J 0---57 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100') 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
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) - t J Method of test: Air Flow 24c.For Water Suoniv&Injection 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: 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