GW1--06527_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ;,
1.Well Contractor Information:
Robert Teague 1'4:WATERZONEs f. r _..
Well Contractor Name FROM TO DESCRIPTION
2857-A 25 oft. 9 a eft. 2 inn y'''.
NC Well Contractor Certification Number
15,.OUTER.CASI d(formulpreaseCvells)ORLINER:(ifap dcatile) .
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. C)ft. 61/8 ' in, SDR-21 PVC
Company Name
16.iNNER CASING OR TUBING;(t eothertnafclosed loop): 4:i-- J.,"-
2.Well Construction Permit#:r:I((��,O — 2 V{L 1.FG. 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:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Et Residential Water Supply(single) ft. ft. kr.
Industrial/Commercial pResidential Water Supply shared
PP Y(shared)
Irrigation FROM TO ,MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecove
ry ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge D.Groundwater Rcmcdiation
'19CSAND/GRAVEL PACK-(if applicable) • -
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL _ EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. I
Experimental Technology EtSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ''20.DRILLING LOG(attachadditionalslieets if neceistiry)"`
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color.hard ss,soil/rock type,grain size.etc.)
( g/ g Other(explain under#21 Remarks)
0 ft. Q' 0ft. c) 1 6� Ck,,
4.Date Well(s)Completed: Well ID# V ft. C, -ft. 1,
5a.Well Location: r1 a.e'ft• 3QS•ft. ar(
Facility/Owner Name‘ Facility iD#(if applicable) ft. ft. tp ;'".) ,7:. 7^�'
i
`(-\) pJ ft. ft. ( T
PhysicalAddress,City,andZip \L ft. ft. I, Ot, f Y :I 2Q��•
. \9 21't REMARKS ,,. • i
I it..vca it .;:3 R.:
County Parcel Identification No.(PIN) ; f i',A:('J:?:'1,::
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certifications
N W ✓ �Li�(7'A Le_ ' 6V/5/1,;Z3 •
6.is(are)the well(s)JPermanent or DTemporary Signature of Certified Well Contra or Date
By signing this firm,/hereby certify that the well(s)way(were)constructed in accordance
7.is this a repair town existing well: DYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 iVell Construction Standards and that a
If this is a repair,fill out known well construction information and a tin 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:
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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: "61 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@l00') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Reso Drees,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 Rota above,also submit one copy of this form within 30 days of completion of well
Rotary
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)_ 0 Method of test: Air Flow 24c.For Water Supply&lniection!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: Chloe Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016