GW1--03580_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD(GW 1)
For Internal Use Only:
1.Well Contractor Information:
Robert Teague
Well ContactorNamc FROM TO DESCRIPTION
2857-A 6C�ft
NC Well Contractor Certification Number ft ft.
B&K Well Drilling Inc -15.,OUTEM CASING:loririalii casedweIIs-ORI:H�EIt;({e"'Titglile
FROM T DIAMET Iffic,NESS I MATERIAL
Company Name 0 6 11- In. SDR-21 pyC
�/ 16 INNER'EASING'ORTUBING- eoUiermalelpyedl 2.Well Construction Permit#:19 1'1 ) 36 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Co[mry.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
FAgricultmal
FROM T
oMunicipaUPublic in.
Heating/Cooling Supply) Residential Water Supply(single)
ft ft. in.
mmercial ®]Residential Water Supply(shared)
18.GROUT
Non-Water Supply
FROM TO ft. MATERIAL •EMPLACEMENT METHOD&AMOUNT
Well: ft.
Monitoring ORecovery
Injection Well: ft• ft.
Aquifer Recharge E)Groundwatcr Rcmediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SANDIGRAVEL PACK if a ticable
FROM TO MATERIAL EMPLACEMENT METHOD}^
Aquifer Test �StolTnwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20:DRILLING I CJG'attach addttionai sheets if neces
Geothermal(Heating/CoolingRerum) Other(explain under#21 Remarks) FROM To DFSCRIPTION(color,hardness,soiUrock ry e, in sire,etc.)`
4.Date Well(s)Completed: - l� �i_ Well I.D# ft. ft, s a
5a.Well Location: ft.
/Owner Name
� - Facility�ID �� ft. ft °: 'r.I....`:,,:e N,:..ii �, a-.,.,6f` ft. MAY 2 2 2Q23
Physical Address,City, ft. ft
21:REhiARitS .: �
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N w
6.Is(are)the well(s)oPermanent or oTemporary ignaturc of Certi�C. .,., Date
�e�cl. BI•signing this form. I herehv cerlfi•that the wellft)was(were!constructed in accordance
7.Is this a repair to an existing well: []Yes or �pNo «irh 15.4.tiCA:0?C.0I00 or'15A NCAC 01C.0200 Nell Construction Standards and that a
Ijlhis is a repair,fill out known well construction information plain the nature ofthe copy ofthis record hav been provided to the well oxner.
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:
1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L V A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@1001)
construction to the following:
10.Static water level below top of casing:40 If warer level is above casing,use--- (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For lniection 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,rota construction to the following:
g rotary,cable,direct push,etc.) ..
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
jj 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (D Method of test: Air Flow 24c.For Water Supply& Injection Wells: In addition to sending the form to
Chlor Tabs' the addresses) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: 1 1t2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Emironmcntal Quality-Division of Waicr Resources Revised 2-22-2016