GW1--03578_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD(GW 1) =rat► >
For Internal Use On
I.Well Contractor Information: ly:
Robert Teague
14rWATE&`20NES
Well Contractor Name FROM TO DESCRIPTION
2857-A a6t0 ft. )-S ft.
NC Well Contractor Certification Number S ft ft
B &K Well DrillingInC 'IS.OUTERCASIN foriaiilti' s ,wells'-OR'LINE&If a'"li¢able
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft ft. 6118 i° SDR-21
PVC
I6'IlVNER'CASING"Ll UBING. euEfieraial closed
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.U!G Cot[nry,State, varies ,e[ ft, ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17:SCREEN
Agricultura] FROM TO DIAMETER SLOTSIZE THICKNESS` btATER.IAL
�MunicipaUPublic ft ft. �
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial ft ft. in.
Residential Water Supply(shared)
Irrigation FROM To. .. s: Y:
Non-Water Supply Well: MATERIAL EM1iPLACEMENT METHOD&4MOUNT
ft. It.
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge E)Groundwatcr Rcmcdiation ft
Aquifer Storage and Recovery Salinity Barrier 19.SANDIGRAVEL PACK if a cable
FROM TO MATERIAL LACE .u.. ly,HOD ,
Aquifer Test 13Stormwater Drainage ft g•. G
Experimental Technology Subsidence Control
ft. ft.
Geothermal(Closed Loop) Tracer .r so:�� it^' wm"jar: �n:f
20.DRILLLNG LOG attach aflditionalsheefs if ne "' .A t .}
Geothermal(Heatm Coolin Return) Other(explain under#21 Remarks) 1011 TO DFSCRIP i wN(color,hard hardauM wrUrock h in size•etc.)
ft. ft.
4.Date Well(s)Completed I Well ID# ft. ft.
5a.Well Location: ft. ft.
l_1��11� 21'�.d� o �e..CT� ft ft
tFac1thty/Owner Name Facility ID#(ifapplicable) ft. ft
Physical Address,City,and Zip ft. ft
L l Y 1 Ld V1 � 2L;RE1FIi�RKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient)
22.Ce o
N
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified We onuactor —"�_
Date
����....,,,,�,,,,//// l�v signing this fium, 1 herebv certify-that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or t*o with 15.4 NCAC 02C.0100 or 1i.4 NCAC 02C.0200 Well Construction Standards and that a
Phis is a repair,fill out known well construction information and OX/ain the nature of the copy ofthis record has heen 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth b tow land surface:__ (ft)
For multiple wells list all depths ifdifferent(erample-JUZ,200'and 2Q100') 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
Ywater 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
(Le.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 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Sunply& injection Wells: In addition to sending the form to
13b.Disinfection type:
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
Amount: t t/2 Lbs 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