GW1--04580_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14::WATERZONES•
Well Contractor Name FROM TO DESCRIPTION
2857-A ft. 6� ft.3 l 6p/1'1
ft ft.
NC Well Contractor Certification Number
•15.OUTER CASING(for'mitltl cased wells)•QR'LINER(If a Ncable) <1; >: ,
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL -
0 ft. /(� ft. 61/8 in. SDR-21 PVC
Company Name •
� 1 /\ 5� 16:'TNNERCASINGORTUBING'.(gedthermalelased4aup
L�f"> )
2.Well Construction Permit#: ��t,/�/' ~hl , 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:
• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. • ft. in.
Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft, in.
QlndustriaUCommercial DResidential Water Supply(shared) Rour .,..
riIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
Monitoring D1Recovery ft. ft.
Injection Well:
QAquifer Recharge QGroundwatcr Remcdiation ft. ft.
r'� 19.SAND/GRAVEL:PACK'if " • -
0Aquifer Storage and Recovery 0� Salini Barrier C MATERIALe) . ::D
!�' �' FROM TO EMPLACEMENT METHOD
0 Aquifer Test QStormwaterDrainage ft. ft.
QExperimental Technology EiSubsidence Control ft. ft.
QGeothermal(Closed Loop) EfTracer
-20:DRILLL'VG 1QG(atfaeh sdditiooal sheets iL necess9ry)-:'
0 Geothermal(Heating/Cooling Retum FROM TO DESCRIPTION(color,ha ass,soil/rock type,grain size,etc.)
( � g ) Other(explain under#21 Remarks) 0 (t. t 67 ft. 0 1,� ��^A 1
4.Date Well(s)Completed_16� Well ID# ) V 7 rsl/` Sf•c-_ / (.� r- `-�
5a.Well
/� a Gitt2(s ft j!),z7�r—t , CS G—pf l��`�
t�-1 1' I l pn ek}1 t-1U Va) ft. ]ft 1 "�['�
Facili /OwnerNamc ft. ft " S;tY Facility ID#(if applicable) �"
s t5 i A
1.573C. (z1 U ) 1 4�c� 2O 3 G ft. ft ,..
Physical Address,City,and Zip ft. ft. J I l j I 1 / an
.-•-1 h co)t't t'� '/4-a D (3'3'f 2i:.RElvARKS
Y '
s.,-- n / 3 ,.nnl
County Parcel Identification No.(PIN) Ifa" ° rat ; tc ,.,I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificafto��
N W . J -e 0 -- o�,3
6.Is are the wells :Permanent i ac�ertified Wei Is(are) O� or QlTemporary Sn ntractor Date
By signing this form,I hereby certiJit that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or No with 15A NCAC 02C.0100 or 15A NCAC.02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information plain the nature of the copy of this record has been provided to the well owner.
repair under#2l remarks section or on the back gjthis 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: (X SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 c 5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi[ferent(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
(i.e.auger,rotary,cable,direct push.etc.) construction to the following:
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 O Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2 Lbs 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