GW1--04583_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 fr,) k2
CRIPTION
2857-A .2-S C d-C-.ft. �-
NC Well Contractor Certification Number
ft.
3ft- ?
15.OUTER CASING(for muWcas wells)OR LINER(if ap flyable)
B & K Well Drilling,lnc FROM TO DIAMETER THICKNESS MATERIAL
D fL {d V ft. 6 1/8 in* SDR-21 PVC
Company Name
1 :16.INNER CASING OR TUBING(geothermal closed-loop) •
2.Well Construction Permit#:l4Va., -62-?5'7 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: iZ.SCREEN
FROM ' TO DIAMETER SLOT SIZE THICKNESS MATERIAI.
DAgricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
DIndustrial/Commercial DResidential Water Supply(shared) 18:GROUT •
(Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring rpRecovery ft. ft.
injection Well:
IDAquifer Recharge DGroundwatcr Rcmcdiation ft. ft.
A uifer Storage and Recoveryp�Salmi Barrier 19.SAND/GRAVEL PACK(if applicable)
q g tY FROM TO i MATERIAL EMPLACEMENT METHOD
DAquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLLNG-LOG(attach additional sheets if necessary):- ; °<: :-:,.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0' FROM TO DESCRIPTION(color,hard esz soil/rock type,Brain size etc.)
ft. 1 r d ft. 6f r� ,1 0,,R.
4.Date Well(s)Completed - /2.-�mS Well 1D# d L.0 ft. t:1$ft. ..c \ 12 1 Sr��� 4''
5a.Well Location: 'l;a ts� ft.
L/ ft. 1. 61 r \+�`� SC�� UQ
s e I:'5 l J r lY.s.�� ft. ft. 1� +�
Facility/Owner Nameft. ft.
tYC �/ � Facility ID#(if applicable)t� 1 _ T •, ...
G b $iVyc`<{ 17�Y1 , Kc�o le.l ft. ft. Y ?.,
Physical Address,City,and Zip ft- ft. 2023
`23vI
L 1 r�c16 khA.6 v\ 21.REMARKS J IJ! 1 r
County Parcel Identification No.(PIN) :CI ^n .;))-:--! ..;.. .,2 IIra
DWC:,JtY-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certific
N W 6 ,I-.7-o?:2
6.Is(are)the well(s)0Permanent or OTemporary gna[urc of Certified We Con or Date
Br signing this/Lrm, i hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or o 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 information and ex 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: .
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: ! SUBMITTAL INSTRUCTIONS
9.Total well depht"below land surface: L(G 5- (ft.)
For multiple wells list all depths ifd item(example-3�a`200'and 2@i00') 24a. For All Wells: Submit'tHis foiin within 30 days of completion of well
construction to the follow
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-I617
11.Borehole diameter: 6 1/8 (in.)
24b.For Infection 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)4i Method of test: Air Flow 24c.For Water Supply&Infection Wells: In 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: 1 112 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