GW1--03583_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD (GW 1)
For Internal Use Only:
1.Well Contractor Information:
Robert Teague
Well ContractorwATER:ZONES:actor Name PRO TO DESCRIPTION
2857-A L j ft. 6 a ft.
NC Well Contractor Certification Number ft. ft
B 8t K Well Drillin Inc 1S.0UTER CASL*iG'.foriaditi cased'wells OR:L1NEF tf ''Ii¢atile r!
g FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft fL 61/8 1° SDR-21 pvc
—�— 16;TNNER'CAS G OR T[JBING eotherival closed<I
2.Well Construction Permit#: r 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U ,County,Stare,variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
IN
ater Supply Well: 17:;SCREEN?
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS Il(ATERIAL
�Municipal/Public fr, ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ndustrial/Commercial fL ft. in.
Residential Water Supply(shared)
1&GROUT .,
IrrigationaeFROM 'TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: ft• ft.
Monitoring Recovery
ection Well: ft• ft.
quifer Recharge Groundwater Remediation ft. fr
quifer Storage and Recovery Salinity Barrier 19.SANDIGEO VEL:PACK da 11c ible.
FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test []Stormwater Drainage ft. ft.
xperimental Technology Subsidence Control
ft. ft.
eothermal(ClosedLoop) Tracer 20.DRILLINGLOG.`attachadditionA heetsifnecessaeothermal(Heatin Coolin Retum FROM
Other(explain under#21 Remarks) To DFSCRIPI fON(color,hardness soillrvck type,A ram size,eta)
r .
4.Date We
Completed:1 Well ID# C� ft. ft.
5a.Well Locati�o/ny:� fc. ft.
.( f� ft
Facility/OwncrNamc S Facility ID#(ifapplicable) ft. ft
ft. fftt.
Physical Address,City,and Zi L - ft. ft
L "` rl g L f 2L REM ARKS':
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/mjnutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N W
—14 1 7- a�
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Wcll ctor Date
13v signing rhis firm,I hereby certify that the w•ell(sl was(were)c•onatructcd in accordance
7.Is this a repair to an existing well: []Yes or No with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 lVell Construction Standards and that a
1f this is a repair,fill out known well construction information a' lain the iiature ojthe copy of this 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:_ n
IN SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdijjerent(example-3@200'and 2@100')
construction to the following:
10.Static water level below top of casing:40
if water level is above casing.use'•+" (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Injection 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