GW1--06514_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 6 �1� i' 6iW
1.Well Contractor Information:
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Robert Teague _ _ i
Well Contractor Name i_y e, '' '- ' 14::WATER ZONES: t I
,w + ii FROM TO DESCRIPTION
2857-A - .0 I` ?, M�,, f p5.ft. i 6 Q 6 ',!�
NC Well Contractor Certification Number O C T 1 1 2 n 3 ft. ft. I
F"
B&K Well Drilling Inc 15,OUTER CASING ffor multi-casedwells)OR LINER(if ap licalile)=1.-:.,. ._mo t
Iry l• . ,:.-;1 r;-..rs•,.;, ,11
re FROM TO , DIAMETER THICKNESS MATERIAL
Company Name L y' ;+`i�j •
0 ft• f l2ft• 61/8 in' SDR-21 PVC
� t .16..INNER.0 5_I/NG OR TUB1NG4geothermaINosed-loop) ti:
2.Well Construction Permit# R``'v -OS I 2 FROM 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
Agricultural FROM TO DIAMETER SLOT SIZE THICK,YE6S MATERIAL
°Municipal/Public ft. ft. ,in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared)
'9 Irrigation 18•GRODT ; ;:.: .
FROM TO MATERIAL EMPLACEMENT METHOD&A.MOUNT'
Non-Water Supply Well: ft, ft.
Monitoring ()Recovery
Injection Well: ft• ft.
g
Aquifer Recharge DGroundwater Rcmcdiation ft ft
'19.'SAND/GRAVEL PACK(if applicable) ,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) Tracer
20.DRILLLNG LOG(attach additional sheets if a •
°Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) etxsY)
FROM TO çSCRI ION(color,haso l/ro ktype,gram size,etc.)
cc-�� i�3ft. ; CDC
4.Date Well(s)Completed" l 3-4 '3 Well ID# I LI3 ft. t- k \ _
tea.Well Location: _� ft. ft. �_rJ 4 s CTP
1 t,�'
/ ft. ft.
Facility/Owner e( ) �-� �l(/ Facility ID#(if applicable) ft. ft. ' •
3\\e1 ro c\ LN ft. ft. '
Physical Address,City,• Zip ft. ft. '
t
Coun1 n 21.REMARKS.::;` •_ .
t �� 1( l Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N W
6.Is(are)the well(s)01Permanent or ()Temporary
..../"...-77-- 9 -I. 3 —d-g
Sign tux of ertified Well Contractor Data
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C'.0200 Well Construction Standards and that a
If this is a repair,fill out known well construe on i rmalion and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the' ck 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-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 elow land surface: '
For multiple wells list all depths if different(example-3,. 00'and 2Q/00') ons c
(ft) For MI Wells: Submit this form within 30 days of completion of well
construction CO the following:
10.Static water level below top of casing:40
ywater level is above casing,use-+• (ft.) Division of Water Resources,Information Processing Unit,
.6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ;
(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Rota above,also submit one
12.Well construction method: Rotary copy of this form within 30 days-of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �� Air Flow 1
Method of test: 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 1/2l.bs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rcsourcesl
Revised 2-22-2016
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