GW1--04658_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
FROM TO DESCRIPTION
Well Contractor Name
a kAr 'Is aft. Cf V\
2857-A •
NC Well Contractor Certification Number Jt. I-•. 6 C.ft. I,,, i(ra�-
15..6>`UTER CASING(for muRf-c)tseclA ells)OR LINER(if a licable)
B &K Well Drilling Inc FROM 14TO �) DIAMETER THICKNESS MATERIAL
0 ft. Y ft. 81/8 in' SDR-21 PVC
Company Name 1 U
/�,y�/._
'16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Perms !; - FROM TO [ DIAMETER I THICKNESS MATERIAL
List all applicable,well construction periiirts((i.e UIC.County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Su PP ly Well: 17.SCREEN
FROM I TO I DIAMETER SLOT SIZE 1 THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Et Residential Water Supply(single) ft ft. in.
DlndustriallCommercial DResidential Water Supply(shared) ..18.GROUT '
rrtgation FROM TO i MATERIAL EMPLACEMENT METHOD&AMOUNT
No Water Supply Well: ft. ft.
0 Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
0 Aquifer Recharge DGroundwater Rcmcdiation
19.SAND/GRAVEL PACK(if applicable)
0 Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
0Geothermal(Closed Loop) OTracer 20.DRILLLNG LOG(attach additional sheets if necessary)
F3s1 l TO DESCRIPTION(color.hardnes�'f iUrock h. e,grain size.etc.)
Geothermal(Heating/Cooling Return) 4 ' V
4.Date Well(s)Completed C9-a1Other(explain under#21 Remarks) ft. gi•d ft. a 1 J -Well ID# k ft. , ft. h co,D J 1) r �� [&y'i �`
ik
5a.Well Location: ).t, Cft. 1 y1 ft �/,y-13 S `Q,/ � � f,e
5 Li( f1�'1101,Y)d 44. 5ft. .s S ft. le-1U�'7 vd g/tr. ! .
Facility/Owner Name �" Facility ID#(if applicable) ft. ft• 1 rr�z..-a -,--.
o a \Al g"y 16 V -e ft. ft. L-..4..,,.L,.a '�, t--2.,,.
Physi I Address,Ci •and Zip ( ft. ft. J IM 1 A 9OZ1
F r, L) 21.REMARKS 1 t l.� �L7\ 1nt:Cfci ricfl P',r't.:r.+:::,..7 ut'st
County Parcel Identification No.(PIN) r„t.; ;.,� ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi lion
N W �/ C' 5-- � '< -' --.-7�
6.Is(are)the well(s)OPermanent or EtTemporary l`maturcof Certified We ontractor Date
Br signing this form.!hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or No with 15.4 NC.4C 02C.0100 or 15.4 NCAC 02C.0200!Veil Construction Standards and that a
If this is a repair,fill out known well construction information n e_rplain 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 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 de elow land surface: SG (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdijjerent(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
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(um), ) \ Method of test: Air Flow 24c. For Water Supply&Injection 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 1/2 Lbs 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