GW1--04576_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: �.Y
1.Well Contractor Information:
Robert Teague 14:•WATER.ZONES: ..: ..
FROM TO DESCRIPTION
Well Contractor Name
2857-A itio ft. �Cr
��� ft.
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-.cased=we113)UR'L1NER'(if' le):::. ': '.?(',...`i
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. q 3 ft. 61/8 in' SDR-21 PVC
Company Name
1&INNER'CASING-OR.TUBING:(geothermal etosed:Idop) .
2.Well Construction Permit#:iff'1Nts1)-3-6--).. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
77:.SCREEN::
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
O Agricultural OMunicipal/Public ft. ft. in.
O Geothermal(Heating/Cooling Supply) EtResidential Water Supply(single) fL ft in.
Industrial/Commercial OResidential Water Supply(shared) GRour - • ..:.
"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
0Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
DAquifcr Recharge 0Groundwater Rcmediation
=;19aSAND/GRAVEL:PACK'(If applicable).....:.
©I Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLLNG LOG(auacli'additiouslsheets if necessary") .:: ..e
FROM TO DESCRIPTION(color hardness.soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) rilOther(explain under#21 Remarks) O ft. /31'S ft. <�(
4.Date Well(s)Completed,-` Well ID# G13 ft.3,6 Sit. kw erp4`� [�j.
Ti5a.Well Location:
• ft. ft. „�1��� �L
R �./`..� ND .7 ft. _ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft.
1 X1 NY IGta r 1=�� -- ft. ft. c .,,' a e,' .—_
Physical Address,City,and Zip ft. ft. J 1J 1 I. 21171
21.REMARkS
County Parcel Identification No.(PIN) ni�-, t ..
lncc-rt ::.,I t:s,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W aC — a...2
6.Is(are)the well(s)OPermanent or EITemporary Si to of Certified Well Con ctor Date
By signing thy firm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constru on'formation and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on th ark 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 d th below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example- @2 0'and 2@100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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
13a.Yield(gpm) a Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2Lts completion of well construction to the county health department of the county
where constructed. 1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016