GW1--06531_Well Construction - GW1_20231013

• P�ntForm •
WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor information: �
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Robert Teague .14:WATERZONES I
Well Contractor Name
FROM TO DESCRIPTION
2857-A I t40 ft. /J ft. "6 14�h—►
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap ticable) •
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name b 0 ft - P-eft. 6 1/8 'tn• SDR-21 PVC
�5�61 F RONNER.CASINGVVOR TUBiMTeothermal dosed-loop)THICKNESS
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County.State.Variance,etc.) ft. ft. 'in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN . . •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EEResidential Water Supply(single) ft. ft in:
DIndustrial/Commercial DResidential Water Supply(shared) 18:'GROUT •
('Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring 0Recovery ft. ft. '
Injection Well:
ft. ft. I.
0Aquifer Recharge Groundwater Rcmcdiation
Aquifer Storage and Recovery OSalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
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[� FROM TO MATERIAL: EMPLACEMENT METHOD
Aquifer Test • DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft. .
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) . . ...
Geothermal(Heating/Cooling Return) FROM TO DESCRI TION(color.hardness.soil/rock type,grain size.etc.)
g/ gg' ) Other(explain under#21 Remarks) 0 ft 7 D ft�,` i 4 �G�,)_
4.Date Well(s)Completed:;, 2 Well ID# 7 b ft. 7r_ �4 ft.�J >`�{ 4 S b4��' `�1,
.Well Location: ft. ft. 1>"'F>
.r.. '
Facili owner Namc ft. ft.
�/ �F-a�ciplityliD�(ifapplicablc) T �� ,n7�
to 0 ��6t6` Y c) f//`^r /� '(� ft. ft. `t�J
�, Ifs,ar, sI-., �
Physical Address,City,and Zip ft. ft. ;.k.,,•''• .T. .a j�h
©ras.,`-;!06 J .'
r'OAC/4sLII0...— 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient) 22.Certification
N W ,14...., y / a2- a_3
6.Is(are)the wells)JPermanent or DTemporary Signature of Certified Well Co tractor Date
By signing this form./here/se certifi•thin the we/I(s)was(were)constructed in accordance
7.is this a repair to an existing well: Yes oro withISA NCAC 02C.0100 or/54 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information plain the nature of the COPE 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: ` , 05 (ft•) 24a. For MI Wells: Submit this:form within 30 days of completion of well
For multiple wells list all depths if-different(example-3@200'and 2 t@r/00') construction to the following:
10.Static water level below top of casing:40 g,
( ) 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 1/8 (in.) 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) 6,V Method of test: Air Flow 24c.For Water Supply&injection Wells: In addition to sending the form to
Chlor Tabs 1/2 Lbs
the address(es) above. also submit:one copy of this form within 30 days of
13b.Disinfection type: Amount: 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 Resources t Revised 2-22-2016
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