GW1--06529_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only: I 4 �
1.Well Contractor Information:
I
Robert Teague ,
:14:;WATERZONES ..•.....; . 1 1
Well Contractor Name FROM TO DESCRIPTION
2857-A / Oft. 7 7 eft. 3I q h
NC Well Contractor Certification Number ft. ft.
B&K Well Drillin Inc .15..OUTER:CASING(for multi�cased:wetls)ORL'INER.(ifap Hcatile)
g FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' I
3 z) ft' 6 1/6 • in. SDR-21 PVC
^��1 ` •16_INNER CASING ORTUBING(geothermalclosed-loop),`,_. .
2.Well Construction Permit#a t9 1 FROM TO DIAMETER
List all applicable well construction permits(i.e.U!C,County. tate.Variance,etc.) ft. ft in THICKNESS MATERIAL
3.Well Use(check well use): ft. ft. in.
•
Water Supply Well: 17.SCREEN
°Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
°IndustrialCommercial ft• ft. in.
°Residenrial Water Supply(shared) •;
18.GROUT
Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring °Recovery 1
Injection Well: ft. ft.
°Aquifer Recharge °Groundwater Remcdiation ft. ft.
°Aquifer Storage and Recovery °Salinity Barrier •19:SAND/GRAVEL PACK(if applicable) :'-. . _. „ .;...,,.,.;;,; :
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test °Stormwater Drainage ft. ft.
©Experimental Technology °Subsidence Control ft. ft. •
°Geothermal(Closed Loop) °g�Tracer
FBI' 20:DRILLING LOG(attach additionat3heefs.if ueee33ary);
°Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) MRhOOM TO DESCRIPTION(corar,ha ess soil/rock type grain size etc.)
4.Date Well(s) '7�.Compieted:� `��Vell ID# `) f t 3 sit- 8 t r CArx
5a.Well Location: '';• L �
/ faCYj
3\ .. 5•=3--P-Z—
MYTT` ft. ft
Facility/ r Name :
Facility ID#(if applicable) ft ft.
`^h ) 1^1n
) \k\il t----",i—(/_ rT
Physical Address,City,and Zip ft. ft. I s.� ; ,tr 4 s'i.j.
Qkb e,, 21.RE1YIdRKS: O C I Y Zn2 ...
County 3
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 0;:�.°;�,•>,��� " t''"3t1r:1
(if well field,one lat.long is sufficient)
22.Certification: i,
N W 75....... .„%i / i
6.Is(are)the well(s) Permanent or Temporary Signature of Certified W Contractor Date
By signing this form,I herehv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or No with 154 NCAC 02C.0100 or 15.4 NCAC 02C'.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and plain the nature of the copy.of this record has been provided to the ace//owner.
repair under#21 remarks section or on theback 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 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 elow land surface: (ft)
24a.
For multiple wells list all depths ifdifferent(example-3@200'and 2@l00') For All Wells: Submit this YbtTn within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40 ;:
lf water 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
12.Well construction method: Air Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply& Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit ode copy of this form within 30 days of
1 t/2 Los 13b.Disinfection type: Amount: completion of well construction to the1 county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental '
Quality-Division of Water Resources Revised 2-22-2016