GW1--04545_Well Construction - GW1_20230713

WELL CONSTRUCTION RECORD (GW-1�
For Internal Use Only:
1.Well Contractor Information:
Robert Teague
14`sWATERZONES :•;:' :DESCRIPTION
FROMT�
Well Contractor Name Maillitimji
ig
2857-A ► " '" '
NC Well Contractor Certification Number •15:OUTER-CASING.ior.: cnsed wells OIt°LINER'.Ws Oleable
FROM TO DIAMETER IMMIEEMICEE
B&K Well Drilling Inc . a ft. Mal 6 118 t°• SDR-21 121111.1111
,i1CONNER:CASING.OR'Ti3BING. .eotbermal,clos®"MATERIAL
Company Name FROM TO DIAMETER
2,Well Construction Permit#:
fit. ft. in.
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) 111111111111111
ft ft. in
3.Well Use(check well use):
17:SCREEN''.< IIIIIIIIIIII
Well: FROM TO DIAMETER SLOT SIZE THICKNESS
— MATE-
RIAL
Water Supply ft. ft in. _
111 Agricultural DMunicipa1/Public —
Residential Water Supply(single) ft. ft in.
Geothermal(Heating/Cooling Supply) � ;. ., _ ;;: .:
@ Residential Water Supply(shared) :,Ig.:Ggom "', -` - - -
IndgatriallCommercial FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irrigation ft. ft.
Non-Water Supply Well: ft. ft.
Monitoring Recovery
ft.• IIIIIIIIIIIIIIIIIII
fit
Injection Well: ::4
Groundwater Remcdiation (cable
•Aquifer Recharge 19:$ANDIGIU1VELt1'ACK a'' EMPLACEMENT METHODFROM TO
�i Aquifer Storage and Recovery �Salim�'Barrier ft. ft.
ji Aquifer Test 0iStormwater Drainage
Subsidence Control
ft. ft. ,
Experimental Technology -
20.DRILI:LYG T;OG'attach SCRIPTION(coloor.h ness,sorUrock •e, rain size,etc.),
$Geothermal(Closed Loop) ()Tracer FROM To
Geothermal(Heating/Cooling Return)rr�� Other(explain under#21 Remarks) pS ft. _
#9—d7- Well1D#
4.Date Well(s)Completed
ligniliMill
r 1�. • r c� e
5a.Well Location: ft. '
K�e� 1 � Facility ID#(if applicable) ��
Facility/Owner Name ft. ft
61.3 63 j3M\ )r se I' 6a S4 6'" i5o,r sh ft. ft. alligMilat4"1111111111
Physical Address,City,and Zip
21:RENI:4RKS _.
U Yike Il I 1 i 2023
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ce G��. G
a'
(if well field,one latilong is sufficient) 22. /14/ke.__..—f N q L. ' ar '
Date
7.Is this a repair to an existing well: ()Yes or
6.Is(are)the well(s) Permanent or Temporary
ignByat uraturc c this Arm,I hereby centJ of Certified I Contractor v that the well(s) was(were)constructed in accordance
si
o
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information nd plain the nature of the
copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
c.For Geoprobe/DPTn, nly1 G1 or is needed. Indicate Geothermal NUMBERs the wellssam construction details. You may also attach additional pages if necessary.
construction,only 1 G�-1 needed. TOTAL of
drilled: SUBMITTAL INSTRUCTIONS
' C
9.TTototal well depth bee low land surface: ✓ 9 '5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If-different(example-3@200'and 2Q100)
construction to the following:
40 (ft.) Division of Water Resources,information Processing Unit,
10
f eatic level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
Ijwater levell is t above casing.use"+
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection Wells: In a d this ii on form to sendwiting
in the
0 day form
to
comp ed eossoin well 24a
above,also submit one copy of
12.Well construction method:
Air Rotary construction to the following:
(i.e.auger,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
Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
Color Tabs i t/2 Les completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016