GW1--04579_Well Construction - GW1_20230714

Pant Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14:WATER ZONES
Well Contractor Name FROM O DESCR,p'r10N
2857-A 7S ft. ft. , J`'
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name o ft. ft. 6 1/8 in. SOR-21 PVC
.16.INNER CASING OR TUBING(geothermal closed-1oop)::.• '
�d-2.Well Construction Permit#:` '� CO IS FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i. .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 MATERtAI.
Agricultural °Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
R °RIndustrial/Commercial
esidential Water Supply(shared) 18.GROUT: `.':
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge °Groundwater Rcmcdiation
©�Aquifer Storage and Recovery ��'`�),Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
�.l tY FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test °Stormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft. I ft.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG{attach additional sheets if necessary). .
°Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rocke grain sere etc.)
z) ftC1S ft. C �. r�
4.Date Well(s)Completed:5 -1 2."013 Well ID# t^ s ft. 2 6 3 ft.Uha 1,6 La I cl r I�e
AA --
5a.Well Location: 5 ft tl
3`5ft. hir� ;! S o f / i"-,/
t-.€-.1p?)rrnc.,-n 1-k , �V ft. ft.
Facility/Owner� li Name
i dFat
acilityiD#(ifapplicable) ft. f
I-5 Sig u I ( ev_n`� 4r ft. ft. PT.' i` '. it { '1' ,
Physical/ Address,City.and Zip ft. ft.
L( nC. I n1-C\ n 21.REMARKS JIJI_ !_ )0)
County Parcel Identification No.(PIN) Ifl'^ +
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �_ I. =�• '
(if well field,one lat/long is sufficient) 22.Certif o
•
N W ./��� S ' `la 'c313
6.Is(are)the weli(s)OPermanent or Temporary Signature of Certified Wcll nirnc 87-' Date
By signing this Arm, I heretic 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 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction informatio an rplain the nature gfthe copy rf 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: 3 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Li tJ (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@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
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.) g
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service1Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Air Flow 24c. For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs t 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