GW1--06515_Well Construction - GW1_20231013

I I
WELL CONSTRUCTION RECORD GW-1 ` '" 0,I00
For Internal Use Only:
1.Well Contractor Information:
Robert Teague
iI
as waTERzoNEs I
Well Contractor Name _ FROM TO DESCRIPTION
2857-A I.: t 'r. �F-) //is,ft. ,42...aft. �•l.\
NC Well Contractor Certification Number 7 �Stj ft V f't ij ��^
B&K Well Drilling Inc OCT I �� 2023 .FROM ERCASING(formulti;cart ,wells)OR THICKNESS
-Hcable)R
FROM TO DIAMETER I THICKNESS MATERIAL
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Company Name I f. I`
`_;ii� {.^..,D t�...-,.•��^v: ``� r�G�:1 0 ft. ft- 61/8 in• SDR-21
PVC
1 t a��(�y; ' ]b.TNNER C ING OR mimeETeottteruiat cl ou
2.Well Construction Permit# 1..1 —�, FROM TO p},:.
List all applicable well construction permits(i.e.UIC.County.State.Variance.etc.) ft. DIAMETER THICKNESS MATERIAL,
ft. in.
3.Well Use(check well use): ft
ft. in.
Supply Well: •
IZ SCREEN .
Agricultural °MunicipaUPublic FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Geothermal(Heating/Cooling Supply) ft. ft• in.
g pP y) Residential Water Supply(single)
Industrial/Comm ®IR
ercial ft• ft in.
esidentia]Water Supply(shared)
Irrigation IS:GRUUT
Non-Water Supply Well: FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
ft. ft.
Monitoring °Recovery
Injection Well: ft. ft.
ft. ft.
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Aquifer Recharge °Groundwater Rcmcdiation
I9.SAND/GRAVEL PACK{dapplicable}'•'••:
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
°Stornlwater Drainage ft, ft.
Experimental Technology °Subsidence Control
Geothermal(Closed Loop) Tracer ft. ft.
.2k DRILL"ING.LOG{attach additionatslieets.if iuececsery)
Geothermal(Heatin Coolin Return) Other(ex lain under#21 Remarks)
DESCRIPTION(color.b rdness,soil/rock type,grain size,etc.) .
FROM To
(� ft. ft. ( t
4.Date Well(s)Completed: - � Well lD# V ft. ,�6�� }rV�,1 ( p
5a.Well Location: ‹.)ft. '" o 5 ' `Aar() � �/ -- re.),In� •c�
l2 ft. ."--)ft.Facility/Dwner Name Facility ID#(if applicable)G ft.
l ft.
\� - . 4_p* ft. ft.
Physical Address,City,and Zip
- ft. ft.
�h CS2 14 71 REMARKS.
/o_elks, �o 21.
County
Parcel Identification No.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient)
22.Certification: �M
N W
6.Is(are)the well(s)0Permanent or °Temporary Signature ofC�It ntra.17
�r -
Date
7.Is this a repair to an existing well: NIYes or By signing this form.I hereby cert///i•that the well(.$)was(were)constructed in accordance
If this is a repair,fill out known well constructinformation andeYplain the nature of the copy ofth with 15A Cie o has beAC 02C en pro0 or vSA ided si leJ o thewC ell
owner. Construction Standards and that a
repair under#21 remarks section or on the back of this form.
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2
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You
diagram use the back of this l mayto provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also'atiach additional pages if necessary.
drilled:___________________all
3�� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells lift all depths ifdierent/examp/e-3C200 and 2 a/00') (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:40 construction to the following: i'
1
+ M.) Division of Water Resources,Information Processing Unit,
limier level is above casing.use
11.Borehole diameter: 6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.For Infection Wells: In additidn to sending the form to the address in 24a
12.Well construction method: Air Rotary above,also submit one co
(i.e.auger,rotary,cable,direct push,etc.) construction to the following pY of this form within 30 days of completion of well
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow
24c.For Water Su Iv&lniectiln'Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs
13b.Disinfection type: Amount: the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-I I
North Carolina Department of Environmental Quality-Division of Water Resources I
Revised 2-22-2016
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