GW1--03576_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Robert Teague 1:4:•wATER-ZoNES :.'.;--.':-
Well Contractor Name FROM TO UESCRIPTION
ft. ft.
2857-A A
ft. fa
NC Well Contractor Certification Number 15t:.01=- R:CASING'for,multi eased V!e OR11�FE'R tR Hcafile
B&K Well Drilling Inc TO DIAMETER "L
FROM
THICKNESS
I MATERIAL
Company Name 0 ft t. 61/8 in' SDR-21 PVC
1 ^�' I&INNEWCASING'ORTUSWG; eotherni6closed4''
2.Well Construction Permit#: l�` ��— L LJ S� FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Counry,State, Variance,efc.) ft ft to
3.Weil Use(check well use): ft. ft. in.
Water Supply Well: "17.SCREEN r;
FROM TO DIAMETER SLOTSIZE THICKN&SS MATERIAL
Agricultural [3Municipal/Public ft fr. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial E3Residential Water Supply(shared)
PP Y ) 1&GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring ORecovery ft. ft
Injection Well:
fr.
Aquifer Recharge DGroundwatcr Remcdiation ft
19.SAND/GRAVELTACK-if a cable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fr.
Experimental Technology Subsidence Control ft. ft.
Geothermal Closed Loop) Tracer
( P) 20:DRILLLVG LOG:autocue additionsi'sbeets`.ifQecec ;:„a,�.,,
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color•ha ess,soll/rock tv a rain size,eta) ,
fr. ft.
4.Date Well(s)Completed••) Well LD# ft. .
5a.Well Location: ft ft.
Q
ft 21" VI-A
Facility/Owner Name Facility IDT ' a plicablc) ft. ft.
14 -�
� y
Y�����Y •ice,..: .,,Fa....s" fi
Physical Address,City,and Zip 7 ft. ft. MAY I n%J
7.1
Ll n lrr-,\ --�-r--- i J i 21tREMARKS
County Parcel IdentifiicationNo.(PIN) 1fliCiii; 5 ..� Pr c.,:.,;I:_el lai.i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat'long is sufficient)
22.Cert' ca'
N W
6.Is(are)the well(s)oPermanent or OTempor,ry i2_naturc.of`Ccnificd Well Cp6tmctor Date
Xana
Bysigning this lin-m, 1 herebv certy., that the uell(s)wav(were)constructed in accordance
7.Is this a repair to an existing well: []Yes oo with 15ANCAC 0?C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
/j[his is a repair,fill nut known we!/conslruc[ion injormatinplain the nalure o(rhe enpv uJ this record has been provided to the well owner.
repair under 021 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well deplelw land surface: �V� ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 Division ft.
( ) sion of Water Resources,Information Processing Unit,
Ifivater 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
12.Well construction method: Air Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,m construction to the following:
g 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) S Method of test: Air Flow 24c.For Water Suonly&Iniection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above• also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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