GW1--03574_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD GW-1 'Ilrtc ;
For Internal Use Only: F 'i
I.Well Contractor Information:
Robert Teague
WeII Contractor Name 14:WAT 1;'R'$ONES -777
FROM Tp
�'•"
2857-Aft. ft. DESCRIPTION
CJ i(
NC Well Contractor Certification Number fL ft
B& K Well Drilling Inc is:iOIJIER'CAMG for inultPedii;d Wetts:OR`LgVEg Nil" (liable
FROM TO DIAMETER THICKNESS MATERIAL .,
Company Name p ft t, I
r� 61/8 in. SDR-21 PVC
2.Well Construction Permit#: J��/{�a Z � 16.INNER CASING UR TOSING'" thertitai ctosbd-l""'
List all applicable well construction permits lee.UlC,Cotmry,State,Variance,etc.) FROM fL TO DIAMETER THICKNESS -MATERIAL w,;•
ft. in.
3.Well Use(check well use): f<
ft. in.
Water Supply Well: 17sSCREEN-;:: ..
Agricultural E)Municipal/Public FROM TO DIAMETER SLOTSI7E THICKNESS MATERIAL
Geothermal(Heating/Cooling Supply) ft. in.
g PP Y) Residential Water Supply(single)
Industrial/Commercial fL ft. in.
Residential Water Supply(shared)
Irri ation 18cGROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. f(
Monitoring Recovery
Injection Well: ft• ft.
Aquifer Recharge DGroundwatcr Rcmcdiation ft. ft
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK rf a ticatile
Aquifer Test FROM TO MATERIAL EMPLACEMENT AfETHOD
�Stormwater Drainage fr, ft
Experimental Technology Subsidence Control
h• ft. ,
Geothermal(Closed Loop) Tracer
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) 20.DRILLING LOG attach addthtitial sheets if aecPs
FROM I TO
DFSCRII'fiON(color,hardness,wlymck t e, ram sae,eta),
6 ft. I ft.
4.Date Well(s)Completed: Well ID# ft.
5a.Well Location: y] GS ft ft.
fL
Facthty/Owner Name Facility ID#(if applicable) ft. ft
CL
ft
Physical Address,City,and Zip 1, f(• ` `,uy Y 5`y �j'�"
ft. ft hA Ay , 1,23
L+ ;21.IREi4fARKS.?', .
County Parcel Identification l4o.(PIN) t' .,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certifi
N `1
6.Is(are)the well(s) permanent or J3Tempor2ry S+gy'nature ofCcrtificd Well Contractor
Date
By signing this fru•m,l hereby cerliJp that the wel!(•sl n'av(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No v.lrh IA4 NCAC 02C.0/00 or iSA NCAC 0he well0 Nell (wee)Constr constion Standards and that e
/f this is a repair,fill out known Ave!!construction informad an "plain the nature of the copy of ihis record has been provided to the well o wiser.
repair under#21 remarks section or on the back of thisform.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Site diagram or additional well details:You may use the back of this page to provide additional well site details or well
construction,only I GW-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:
For multiple wells list all depths ifelijferent(example-3(7a 200 a and 2@!00•) -(ft-) 24a. For All Wells: 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,
11.Borehole diameter:
6 1/8 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Injection 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,
L 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
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection e: 1 t/2 Lbs
type: Amount: 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