GW1--06533_Well Construction - GW1_20231013

xnnt Form WELL CONSTRUCTION RECORD (GW-1) 1.
.
For internal Use Only:
1.Well Contractor Information:
I
Robert Teague
r14aWATER ZONES: 1'1
Well Contractor Name FROM TO DESCRIPTION
2857-AD..../._3'. . CS ft. �f i Gn )
NC Well Contractor Certification Number ft. l ft. k
B &K Well Drilling Inc FROM CASING(for mDIAMsed.wells)OR (ffap Nc ATE
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ' a ft. ft. i 1°
`�.��9 6 1/8 SDR-21 PVC
2.Well Construction Permit#z�+( — /y 53 '16.;INNER'C G R TUBINGi{geothermal cloaed400p) .. •-.. - _
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. J in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: •
QAg icultulal QMunicipaUPublic FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Geothermal(Heating/CoolingSupply) ft ft. in.
, Residential Water Supply(single)
°lndusuiaI/Cotnmercial ft. ft. 'in.
°Residential Water Supply(shared)
d8^GROUT Irrigation .. 4•:.:...
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
ci Monitoring DRecovery
Injection Well: ft. ft.
°Aquifer Recharge QGroundwatcr Rcmediation ft. ft.
Aquifer Storage and Recovery QSaliniry Barrier 19•SAND/GRAVEL PACK(if applicable) .
QAquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
OStormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control
ft. g•
°Geothermal(Closed Loop) °Tracer
.20.DRILLING LOG(attach adilitionatibeets if neeessaryy.
OGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ;�� TO DESCRIPTION(cots hardness.soil/rock type,grain size,etc.) '
/ > ft. ft. tet,;z4.Date Wells)Completed:� Well ID# )r.� ft. 2 � '
ft.
5a.Well Location: ;x: C ft. elf ft
Gc Sr ���
STe P n �l 1V R. ft _._
Facility/Owner Name �a� r' N Facility ID#(if
fapplicable) ft. ft. 1,7 t>A SV I& C fJy to U e, . ft. .6""", t fi i' -i`. • i w '-,.
Physical Address,City,and Zip ft.
21,:REMARIC3 :... ft. 0 C T 1 i121'2 a
County Parcel Identification No.(PiN)
Informs.:;!.^n lPr:;,. i. .tea URA
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G "J' rZ�
C-C-A h G.1 b e-.
• (if well field,one lat/long is sufficient)
22.Certificationt� I.
N W
6.Is(are)the wells) Permanent ' or Q p ry ���� 5 - J LI- d..••�
Tem ora Signature of Certified Well Contractor i, Date
7.Is this a repair to an existing well: QYeS or No By signing this form,1 hereby certiJi•that the well(s)was(were)constructed in accordance
If this is a repair,fill out known well construction information nd rplain the nature of the withp )f th5.4 is record has b AC 02C.0100 n provided to h o2 e.0200 owner.
I Well Construction Standards and that a
repair under i#2/remarks section or on the back of this form. copy o
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
drilled: of wells construction details. You may also attach additional pages if necessary.
•
9.Total well dept feidw land surface: S SUBMITTAL INSTRUCTIONS
For multiple wells list all depths rjdiferen,/eramp/e-3@200 and 2 I00') at) 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:
"Twiner level is above casing,use"+ (ft•) Division of Water Resour yes,Information Processing Unit,
6 1/8 1617 Mail Service Ceti'ter,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: (in.) �
24b.For Infection Wells: in addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above,also submit one
(i.e.auger,rota P ) copy of this form within 30 days of completion of well
B rotary,cable,direct us etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) } S Method of test: Air Flow 24c.
For Water Supply&Injection'Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs
I3b.Disinfection type: Amount: the address(es) above, also submit o'ne copy of this form within 30 days of
completion of well construction to the iounty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016