GW1--04578_Well Construction - GW1_20230714

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
2857-A 3 G 0 ft.3 7 0 n-3, Gi ja'1
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ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a usable) . . ......
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. G1� fL 6 1/8 tn' SDR-21 PVC
'16.INNER CASING OR TUBING(geothermal closed-loon):.," .. .•.
2.Well Construction Permit#: 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: 17:SCREEN
'•' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAI.
°Agricultural OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
()Industrial/Commercial OResidential Water Supply(shared) 18:GROUT, : .
11 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD-&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring E3 Recovery ft. ft.
Injection Well: —
ft. ft.
Et Aquifer Recharge OGroundwatcr Rcmcdiation
A uifer Storage and Recoveryp�Salmi Barrier 19.SAND/GRAVEL PACK(if applicable) '
Q g 0 Salinity FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test OStormwater Drainage ft. ft.
()Experimental Technology °Subsidence Control ft. ft. '
°Geothermal(Closed Loop) OTracer 20.DRILLING.LOG(attach additional sheets if necessary)
()Geothermal(Heating/Cooling Return) FROM DESCRIPTION(color.ha'�]ess,soil/rock t pe,grain size.etc.)
( g/ g nOther(explain under#21 Remarks) 0 ft. 11::"..kfO
e ft. \ • r {_ gl ca _
_1 (� l �S )Y� K
4.Date Well(s)Completed S.—l S—�3 Well ID# err s ft. ^vs ft. ) ',_\ ,7 i�C
Sa.Well Location: �V/ ft. L.f( ft. f"1 a r.) (4-S 8'F fC7
1 j e.
1A c.1 Ms �C -S
Facility/Owner Name NMI
11 .1 Facility ID#(if applicable) ft. ft.
1 5 a.G N lS l l U L c)"c.y,J. ft. ft. lA (^ {". u
Physical Address,City,and Zip ft. ft.
LlItcz\htOn 21..REMARKs Ail i i ZCc3
County Parcel Identification No.(PIN) irt<c--r-'ic
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif n:
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N W 1 ) S O11
- lSr -3
6.Is(are)the well(s)01Permanent or °Temporary ignaturc of Certified Wel ontractor Date
Br signing this firm.I hereby cert?i that the weals)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200(Veil Construction Standards and that a
If this is a repair,fill out known well construction infiirntation a xplain 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 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: L..` 1 SUBMITTAL INSTRUCTIONS
9.Total well depth{below land surface: �l (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2 c@I00') 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
12.Well construction method: Air Rotary above,also submit one copy of this form within 30 days of completion of well
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) 3 Method of test: Air Flow 24c.For Water Supply&Injection Wells: )n 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 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016