GW1--04656_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD.(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14:WATERZONES >:i: .. ... ,
Well Contractor Name FROM TO DESCRIPTION
2857-Ap.3b ft. a y 0 ft. ? 6l ©
ft. ft.
NC Well Contractor Certification Number 15:iOU71,ER CASING.(for multi..eased wells):OR'LINER'(It•.: ble)
B&K Well Drilling Inc FROM TO�.) DIAMETER THICKNESS MATERIAL
a ft. cY ft. 61/8 in* SDR-21 PVC
Company Name C7
1
� ^� Q -`16.INNERCASING..O&TUBING:(geothermal.clased Iaop).
2.Well Construction Permit#: .(1�' D 1 5 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County, rate,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) EllResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Rcmcdiation
619i$AND/GRAVER:PACK Fif aPPliiilble). ': .;= ,.. .::,.'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheeti'if n ssry)::
Geothermal(Heating/Cooling Return) u FROM TO DESCRIPTION(color,4 ness,sal Wrack type,grain size.etc.)
( g/ g Other(explain under.r21 Remarks) 0 ft. 9 S fr. ;lA
4.Date Well(s)CompletedW d rX3 Well LD# 01
¢l ft. ,),..6 S ft. ctx, ) •1)(,,
5a.Well Location: .US ft. I(. S-ft' %%%�???l [� `SSO
jkt—e,V e� 41 r' \c.\ -\lc`\4�� ft. ft. J�1
Facility/Owner Name Facility ID#(if applicable) ft. ft
ft. ft.
Physical Address,City,and Zip
CCAk ad.)l' e.‘
County Parcel Identification No.(PIN)
in4vYrt«,::1 c.i)i'r.7.•:o,-ye:f,2 01,,2.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n13:',•t1 r•+12
(if well field,one lat/long is sufficient) 22.C ification:
N W J J c.„A-744.717.44.___
-5- c)3
6.Is(are)the well(s)0Permanent or Temporary Signature of Certified WW C Date
By signing this Arm,I hereby cert jy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or [No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information an 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:
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
o 5 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40 ft.
If water level is above casing,use'+ ( ) Division of Water Resources,Information Processing Unit,
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
12.Well construction method: Air Rotary above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLYWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636/
13a.Yield(gpm) li. '`.2, Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabsthe address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2I_bs completion of well construction to the 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