GW1--03573_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: c� ,
1.Well Contractor Information:
Robert Teague 14.WATERZoxEs
WeilConrractorNamc FROM To DESCRIPTION
2857-A �s ft. a ft. Jr
b G..
ft. ft.
NC Well Contractor Certification Number
15'OUTERCASING'formultl�.cased°wells OFiTmR ffa`rrebie a,.
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. ft. 61/8 in. SDR-21 PVC
1�l�] /�1 _/C )/ "It.MNER'GASING OR FUBWG. eatherma7 closed loo:
2.Well Construction Permit#: � rV d C 3 —3t� FROM TO DIAMETER THICKNESS MATERIAL '
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: :,17:SGREEN .;:
Agricultural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
�Municipal/Public ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
Irrigation 18,GROUT:.: :;;:
FROM TO MATERIAL EMPLACEMENT METHOD&A.v1011NT
Non-Water Supply Welli rL ft.
Monitoring Recovery fr. ft.
Injection Well:
Aquifer Recharge DGroundwatcr Remediation ft. fr.
Aquifer Storage.and Recove 19.SANDIGRAVEL PACK if n llr9ble ry Salinity Barrier FROM TO MATERIAL EMPLACEMENTAfETHOD
Aquifer Test oStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer
20.DRILLING LOG:attscti'9dditintial:sheets if:neces
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color•6a ness.solurock a gmin size,eta) +*
7S ft. ft.
4.Date Well(s)Completed: _ Well ID# 'ft. ft.
5a.Well Location:
ft. <fL -
Facility/Owner Nam Facility ID#(if applicable) fL ft.
Physical Address,City,and Zip ),_
fL E
-�i !1�=2LJ� 2LRE14IARK$
County Parcel Identification No.(PIN) I I I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Inrv�
(if well field,one lat(long is sufficient)
22.Certification:
N W �•
6.Is(are)the well(s)oPermanent or Temporary TM, Ignature ofCeriificd Wcll Contra r Date
Iry signing this Jorm.l hereb.v cert6 that the ire//(s)nac(were)c•onsnucted in accordance
7.Is this a repair to an existing well: [3Yes or No frith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 11'ell Construction Standards and that a
ljthis is a repair,fill out known well construction in ormation d � copy o this record has been provided to the well owner.
f plal,t nature of the P J
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 GW-I 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:list all depths A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list (example-3@200'aced:@!00')
construction to the following:
10.Static water level below top of casing:40 ft.
))water level is above casing,use + ( ) Division of Water Resources,Information Processing Unit,
6 1/$ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For►niection 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Senice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ls� Method of test: Air Flow 24c.For Water Supply& Iniecton Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: t t/2 Lbs completion of well construction t1 the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Qualiry-Division of Water Resources Revised 2-22-2016