GW1--04582_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 TO DESCRIPTION
2857-A ��� ft. � ft �
ft ft.
NC Well Contractor Certification Number
15:.OU3`ER CASING(ioriiiiiltkitsed wells)OR LINERlif rrcable)
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
'0 ft• !y bt. 6 1/8 in• SDR-21 PVC
1 >16-INNER'CiASING.QR-I RING:(geotbeimateloSid:luop)"
2.Well Construction Permit#: W ?-'�`/—� q 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: 1:7::SCREEhi ;;
• FROM TO • DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
QGeothermal(Heating/Cooling Supply) EIIResidential Water Supply(single) ft ft. in.
DIndustrial/Commercial OResidential Water Supply(shared) .
I' Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
13 Monitoring oRecovery ft. ft.
Injection Well:
A uifer Recharge ft. ft
9 g riGroundwatcr Rcmcdiation
uifer Storage and Recovery19i:'SAND/GRAVEL.PACK'(ifapplicable)
9 g ()Salinity Ranier FROM TO MATERIAL EMPLACEMENT METHOD `
A
0AquiferTest DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
QGeothennal(Closed Loop) ()Tracer I....J' Zo:DRILLLNG iOG(attacb saditioiutlstieetsidnecesaaiy) -- .
Geothermal(Heating/Cooling Return) Other(explain under#2I Remarks) FROM TO (1D�ESCRIP7ION(coAlor. ess soil/rock type grain sae etc.)
4.Date Well(s)Completed' —�� 7P ft. ILO'
`)j•C,�
Well ID# j 1 T�ft• a...o ft. ��rr//✓✓�'
Lipp.
ft. t.L� h 't S� n Sa.Well Location: 9-6 �4
\gale nc�G fjrick ft ft
Facility/Owner Name g
Facility lD#(if applicable) ft ftS c JM rrlt .GCS W a ft. ft. _ 7)Physical Address,City,and Zip • ft. ft &... r v"
GI��by
' ' 'Vh /6 .Zrs 21.REMARICS. jI!t '<
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IP.t'. '`' l r W j w
(if well field,one lat/long is sufficient) ;;-;v:
22.Ce}rtifi Son: �
a&,,./ -6-% -..)-3
6.Is(are)the well(s)01Permanent or E3Temporary Signature of Certified Well Co ctor Date
By signing this Arm, I hereby c•ert(fj that the wedgy) was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or o with 15.4 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction information explain the nature of the copy of this record has been provided to the well owner.
repair under#2/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 GW-I is needed. Indicate TOTAL NUMBER of wells construction details: You may also attach additional pages if necessary.
drilled:
3 SUBMITTAL INSTRUCTIONS,
9.Total well epth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(1dii 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:
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) tl`13 Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection Chloe Tabs 1 1l2 Lbs the address(es) above, also submit one copy of this form within 30 days of
type: Amount: completion of well construction to the county health department of the county
where constructed.
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016