GW1--06516_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
Robert Teague
:14:WATER Z(?NES .: ,; I I ;.. .,:,t:;'• :'.
Well Contractor Name r:'`i r ,L_ "s ,-•',•- FROM TO DESCRIPTION/
2857-A ,,,��'„• ;..i. V r'1�) 2-3 �4 4,1 C�• G '-a.-,.
NC Well Contractor Certification Number O C T ! 2023 ...2- N R•2 u k)OR
15..OUTER. MINGO&-ulti,eas• .wells)OR-LINER: fap licable), ;;
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name DW �`n ft 7 O fL fill$ In' SDR-21 PVC
/ L , 76.:INNEITCASING ORTUBING.'{geothermal elosed=luog)°
2.Well Construction Permit#: OG
L r �S 2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft• in.
"•17.SCREEN'
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural EtMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) MIResidential Water Supply(single) ft. ft. ,in.
DlndustriaUCommercial DResidential Water Supply(shared) ,
('Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. ,
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Rcmcdiation
19.SAND/GRAVEL PACK(if applftltble)'. .: • •
DAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology EtSubsidence Control ft. ft.
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DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additidtiatsheets if tieeessaey)"
Geothermal(Heating/Cooling Return) FROM •ro DESCRIPTION(color.hardness•soil/rock type,grain size,etc.)
( g/ g1 rtOther(explain under#21 Remarks) ft, Tr) ft. 1;�-� �S
4.Date Well(s)Completed ".G J a-3Well ID# �� ft� ft. fir- _ '
5a. ell Loco ion: e (�(S C 11..6 o LAi--� A S E� T/� 7r
j - _ `�b 5 ft.s.r�-r ft. r./- 4 G11_ctied 7"�J(7
Facility/Owner Name • Facility ID#(if applicable) ft. `� ft /z �Q
P • /� k y ?/ ft. ft.
Physical Address,City,and Zip [� '/ �` ft. ft.
1 ral 1 l l in /dDG O 9 2I..REMARKS:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific
N W 8 :aJ_ a3
6.Is(are)the well(s)jPermanent or (Temporary Signature of Certified Well ra Dale
,,,,��,,,,////' 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 114 NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,ft[[out known well construction information nd�, ,lain 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 thls 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 I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 4f2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ....C.b_c* (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2QI00') 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 /$ (in.) I.
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) i 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: t 1/2 u's 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
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