GW1--04659_Well Construction - GW1_20230714

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
7
1.Well Contractor Information:
Robert Teague 14.WATER ZONES ..
Well Contractor Name FROM TO DESCRIPTION
2857-A : 5 ft. ?-' 0 ft. 6 6, Crt�
ft. ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(if a Iicable)
B & K Well Drilling Inc FROM , /TO DIAMETER THICKNESS MATERIAL
Company Name o ft. 1 ft. 6 1/8 in' SDR-21 PVC
16.INNER CASING OR TUBING(geothermal closed-lob .
• . :
2.Well Construction Permit#:�,� - I q S 7C'-j FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County.State. Vail-dice.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 °Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
°Industrial/Commercial °Residential Water Supply(shared) IS:GROUT.::.
II Irrigation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
0Monitoring °Recovery ft. I ft.
Injection Well: ft. ft.
DAquifer Recharge DGroundwatcr Rcmcdiation
E3OSalinity IAquifer Storage and RecoveryBarrier 19.SAND/GRAV.EL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test fStormwater Drainage ft. ft.
©Experimental Technology OSubsidence 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 ro DESCRIPTION(color,hardness soil/rock hpe grain size etc.)
N
4.Date Well(s)Completed -S -.)-...3Well 1D# ft. �,1 S ft. + r� 4. �J_��
5 ft 9 !63 ft. -1 igli�U�
. 5a.Well Location: '1/Jb 5 ft....? $ ft. h�i-c SOf--I t�/i&`
c- cyls}-t-, ki 6 c�rek,1)o f- ft ft t /� , .
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1-t 1 1, 1 'l CN r i i r y 5. 5 c 1 C Pr, ft. fL ...�..i !,., /
//Physical Address,City,and Zip ft. ft.
CC. cr 21..REM4RKS Jijl i •P:: ?LI23
County Parcel Identification No.(PIN) iri+.,„4.3 +`;t ..'.•y ::'.3 l.ft:I'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
D4axv
(if well ficld,one lat/long is sufficient) 22.Certification:
- 17.--/r./-1,,t • 'X---'1'-?.
6.Is(are)the well(s)OPermanent or (Temporary Siena[ rc of Certified Well C tractorle- Date
���...���ppp By signing this Iinxn,l hereby certlii•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 15.4 NCAC 02C.0200 iVeil Construction Standards and that a
If this is a repair,fill out known well construction information and�` explain the nature of the copy of this record has been provided to the well owner.
repair under#11 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: IL3((�� SUBMITTAL INSTRUCTIONS
.3 9.Total well depth below land surface: S (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 2@100') construction to the following:
10.Static water level below topof 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(gpm) (Ct b Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1t2 t bs the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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