GW1--03560_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD (GW 11 f
For Intemal Use Only:
1.Well Contractor Information:
Robert Teague
14.warExzorl>as:;
Well Contractor Name FROM TO
"UESCRIPTIOh
2857-A ) ft. Z
NC Well Conhaetor Certification Number ! ft• aD ft.
B&K Well Drilling Inc "15i.0UPERCASING for,'inalti: sedwells.0R XaRifI "livable
g FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft ft. 61/8 1° SDR-21 PVC
���I 16i:IlYNER'G2ISING'ORTUBlNG' tTerual closetT'
2.Well Construction Permit#:. FROM To DIAMETER THICKNESS MATERIAL'.t
List all applicable well construction permrts(r.e.U1C,Corrnry,Slate,f ariarsre,ere.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
IN
ater Supply Well: 'Y7::SCREEN; ...,,
Agricultural FROM TO DIAMETER SLOT SIZE .THICKNESS` M1tATERIAL
�Municipal/Public ft ft �
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ndustrial/Commercial fL ft. in.
Residential Water Supply(shared)
18:GROUP; : ...
rri ation
n-Water Supply Well: FROM TU MATERALEMPLACEMENT METHOD .AMOUNT
rLMonitoring Recovery
Well: ft• fL
quifer Recharge Groundwater Remcdiationquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL.PACK da If ble
FROM TU MATERIAL EMPLACEMETIETHOD
quifer Test �IStormwater Drainage fc. fr.xperimental Technology [3Subsidence Controlft. ft.
eothermal(Closed Loop) Tracer20.DRII LLNG LQG:attach'sdditfolisl sheetsifae eothermal(Heatin Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(colorb. rain size,etc.)
ft. ft.
4.Date Well(s)Completed: a t —�,� Well 1D# e. ft. V t
Sa.Well Location: � —tt• L..
� .v_ L
'— -1 t
Aa �- ��.f.�y.S —ft. fL
Facility/Owner Name Facility IDI(if applicable) 6 ft - - ft.
``
Physical Y,and Zip l hC �rG SJ` t--t--o i f 'Ct
ft. ft.
county
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
pfwell field one laUiong is sufficient)
22.CertificaC
N W —�
6.Is(are)the well(s)oPermanent or E37remporary Signature of Certified Well Contractor a�
Date
BY
bv
7.Is this a repair to an existing well: Yes or [3No witht154 NCAC 02C.0100eor I5Atify NCACt the welt(� Was(were)constructed in accordance
02C.0200 Well Construction Standards and that a
/'this is a repair, ill out known well constru nn'njorniation and erplain the nature of the copy pjthis record has been provided to the well owner.
repair under#21 remarks section or on the back o 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
�L SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I & (ft.)
For multiple we/Ls list all i'different(example-f(a 200'and 2 cr 100') 24a. For All Welts: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 40
('water level is above casing,use +'• (ft.) Division of Water Resources,Information Processing Unit,
il.Borehole diameter:
6 1/8 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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:
' I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Iniecton Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs the address(es) above, also submit one copy of this form within 30 days of
completion of*well construction to the(county health department of the county
where constructed. j
Form GW-1 North Carolina Department ofEnvironmenial ualiw-
Q Division of\Valet Resources Revised 2-22-2016