GW1--04651_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 i ite()ft. 47c5 ft. /, /, .
4. Oft, 1-7�ft. " G
NC Well Contractor Certification Number [ /TT
15.OUTER CASING(for nihlti-cased wells)OR LINER(if ap livable)
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
a ft. ILI0 ft. 61/8 in. SDR-21 PVC
Company Name
(� :16.INNER CASING OR TUBING(geothermal closed-loop) .
2.Well Construction Permit#: L;�� -! IFROM 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 MATERIAL.
Agricultural OMunicipal/Public ft. ft. in. '
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT:: •
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Rcmediation
Aquifer Storage and Recovery p�Salin Barrier .19..SAND/GRAVEL PACK(if applicable) .
Y�l' i FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. 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/rock type,grain size.etc.)
o f o ft. d,'rJ Mc4,,_
4.Date Well(s)Completed: '- ` -.2.-5 Well ID# I g l7 ft.
-7a,-�e-ft• hart )31 Le trv,0't
r5a.Well Location:c r ^� U-� ft..3 al.ft. j �� {\ ct
Nill c \it Cons- Uc l 1 0y\ �5ft. f I�S fL J L 4 icc..cji /i/Lr
Facility/OwncrName (`i Facility ID#(if applicable) JJJ ft. "l ft. jJ
Ljg2S Nur+111WI 115ierio7 or ft. ft. 1:::� �r Y ; .
Physical Address,City,and Zip ft. ft. ' --- ,.r
C C ; OA 21.REMARKS J I_ll .1 A 2023
County Parcel Identification No.(PIN)
lni\-N t ,l.".•a i'!'•n-f.)(1,i.^YJ lir`t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: na,).%'`:
(if well field,one lat/long is sufficient) 22. ification:
6.Is(are)the well(s)0Permanent or OTemporary Signature of Certified Well C actor Date
By signing this Arm,I hereby cent f•that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with 15.4 NCAC 02C.0/00 or 15.4 NCAC 02C.0200 IVell Construction Standards and that a
If this is a repair,fill out known well construction information nd plain 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 Gay-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
1L/
9.Total well depth below land surface: 6 (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?cr 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 infection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) L Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 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,th'e 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