GW1--04653_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Robert Teague 14t WATER.ZONES
FROM TO DESCRIPTION
Well Contractor Name V A l S ft, w 1 6 ff. , 0 J �'fr.)
2857-A ft. rti ft.
NC Well Contractor Certification Number 15.OUTER CASING(for miila cased'wells)OR LINER{if a licable) ' .
B &K Well Drilling Inc FROM TO DIAMETER , THICKNESS MATERIAL
0 ft. O(z. ft 61/8 ' in' SDR-21 PVC
Company Name '16,INNER CASING OR TUBING(geothermal elosed-loop)
A^2� - FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#02..1 b 3 c ��
List all applicable well construction permits(i.e.UIC,County, tate, ariance.etc.) ft. ft. in.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN..... • ,.:.
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft, ft. in.
Industrial/CommercialResidential Water Supply(shared) I8:GROUT .:.
"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
DI MonitoringRecovery ft. ft.
Injection Well: ft. ft.
0 Aquifer Rcchargc DGroundwater Rcmcdiation
19.SAND/GRAV.EL.PACK(if applicable) . ``
0 Aquifer Storage and Recovery . DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•
0Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. I ft.
DGeothermal(Closed Loop) OTracer 20.DRILLLNG LOG(attach'addttion'al sheets,if necessary).> , " ..
FROM I TO DESCRIPTION(color,b ness,soil/rock type.grain size.etc.)
Dt:reothermal(Heating/Cooling Return)
`2 lOOther(explain under#21 Remarks) ft.�r ft. \ Y� \ + G
4.Date Well(s)Completed -/‘ v Well ID# 4, ft•(aa d eft, hare.)�S"�. 1u f✓
v /7 c
ft. ft.
5a.Well Location:
N icAk 4 z-Y N N / /lc. J ft. I ft.
•
Facility/Owner Namc Facility ID#(if applicable) ft. ft.
5,),7 2 Al G 115 0 (4 W`1 I 0 ft. ft. tP.', 7-- .`3
t ft. ft. t 4 ..'.k...a ti.` i4"`
Physical Address,City,and Zip •
`
C.r.,k c,w b o, 1,REMARKS JULJ U t _ 2023
23
County Parcel Identification No.(PIN)
Ink/m-4 3n P!••:-',. t.r,�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �.�a; ;,�y
(if well field,one lat/long is sufficient) 22.Certifrcati n:
N W �� S-/-C —.:71
6.Is(are)the well(s)JPermanent or DITemporary
ignature of Certified W Contractor Date
By signing this Ibrm,1 hereby cert(/v dial the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or' 'iVo with 15A 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 an explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis 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�is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (>" (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths if difterent(example- @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 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 o 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
Chlor Tabs
13b.Disinfection type: Amount: 1 112 Lbs completion of well construction ilto 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