GW1--04577_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague `14:WATERZONES -1.;.
Well Contractor Name FROM TO DESCRIPTION
2857-A r 7 Oft. /5 a ft.$ ' r,,,
a 4.5 ft. a7O ft..0 'rt.NC Well Contractor Certification Number J
-15.GUTERCASING(for multi-eased wells)OR LINER,(ifrip licable) ,'.
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. /1 /s ft. 6 1/8 in' SDR-21 PVC
Company Name (�J
`, ') j /y :16.1NNER CASING OR UBING.(geothernial closed-loop)
2.Well Construction Permit#: v"^�- O v I /7J T
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.
Water Supply Well: .- .s17:.SCREEN ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
()Agricultural DMunicipaUPublic ft, ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft, ft. in.
()Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
h Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - ft. ft.
0 Monitoring Recovery ft. ft.
Injection Weil: ft. ft.
0Aquifer Rcchargc ..Groundwater Rcmcdiation
©Aquifer Storage and Recovery SalinitY Barrier _'"19.,SAND/GRAVEL PACK(if applicable), _;
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStormwater Drainage ft. ft.
®Experimental Technology Subsidence Control ft. ft.
()Geothermal(Closed Loop) ()Tracer 20.•DRILLING1OG{attach'additionatsbeet'sif necessa yy).
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION color,h ness,soillrock t pe,grain size.etc.)
( g/ g / Other(explain under#21 Remarks) 0 ft. Q n ft. ir,1 8
4.Date Well(s)Completed: t1 6 7 /.2,3 Well ID# 1 o ft. l6U�ft. 114).0
4). -\) i
f ,✓\ R.
ft. CJ
5a.Well Location: A� , J ACjs 3 bs LIG..ryi 4, S _ j/1e✓t
'U rl'k lkc n3 (�V l q a•� ft. ft. s� tt
Facility/Owner Name Facility iD#(if applicable) ft. ft. 7. .— n l r•.•-.7 k
O ft. —
1' J ft. t \..,'I, d - --,.
Physical Address,City,and Zip ft. ft. I IJ I q / 7023
Li-c_a\1/, oY1, ..21c;REMARI(S,; .. .;
County Parcel Identification No.(PIN) 1f i `,6 a i'S
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one lat/long is sufficient) 22. tific2ti
i
6.Is(are)the well(s)0Permanent or Temporary Sinaturc of Certified We ontractor Date
By signing this.form, l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 iVell Construction Standards and that a
If this is a repair,fill out known well construction information and lain 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:
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 et pth below land surface: 3Q,2 (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 2@!00') 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 Infection 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) /e. 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