GW1--06534_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Robert Teague la-WATER ZONES- i I '
Well Contractor Name FROM TO DESCRIPTION
2857-A a s eft a c aft C�p,�-1
4/ t �' I
NC Well Contractor Certification Number 5 OUTER CAs1N r tnulhcase fvells OR'LINER(ff Sp dcatile}
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Corn an Name 0 ft' /4/ / ft. 61/81 ; in• SDR-21 PVC
P y t /
p �+ 1'6J INNER CASING OR TUBING:(geotheruialclosed=loop} :•'_
2.Well Construction Permit#. •3—/9./ 4 O C/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State.Variance,etc.) ft. ft. I: , in.
3.Well Use(check well use): ft. ft. in.
.
Water Supply Well: .17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural 13Municipal/Public ft ft, 'in.
QGeothermal(Heating/Cooling Supply) Et Residential Water Supply(single) ft. ft. in.
0Industrial/Commercial ®Residential Water Supply(shared) i$rGRODT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EiRecovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge 13Groundwatcr Remcdiation •
19.SAND/GRAVEL PACK(if:applirrble) ':-. , •
(Aquifer Storage and Recovery 0 Sal inity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
BExperimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:BRILL(NG LOG(attach additiousl.sheet if accessary}
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color.hard ess.soWVrock type,grain size•etc.)
( g/ Qg_ Other(explain under#21 Remarks) ft. 1 L ft. _\ 1' �A 0�,
4.Date Well(s)Completed:-( ? 1 Well 1D# 1 Gj 1 ft. 3 O S ft. Z7U.rei lS/C/(, . j- ,- - t
5a.Well Location: 3 lJ.mot 36 n, ft. his 1 1� S 3 ra,�li�
L--JX U OA 6� R S I L & ft. ft YV
Facility/ChvnerName Facility ID#(if applicable) ft. ft. ; _
aS� I'ZI6 5- 61r“z Drcrrc l ft. ft. �. _� ,•k:n ,tr _
rPhysiical Address,City,and Zip ft. ft.
(`T 1 " 7(i
Cc��o.•w�e 21 REMARKS ,. .. �` . Pr '��
County Parcel Identification No.(PIN) ID'J(LC**=y+':l (t. rw:a 3 t�-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification://
N W /
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6.Is(are)the well(s)OPermanent or CITemporary Signature of Ccnificd Well C clot Date
By signing this form,I hereby certJi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or t 4 No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200(Fell Construction Standards and that a
IJ this is a repair,fill out known well construction information an. •rplain 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: �. (ft-)
24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C200'andct 2 100') construction to the following: i,
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 1/8 (in.) 24b.For Infection 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'C rater,Raleigh,NC 27699-1636
13a.Yield(gpm) a 0 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
I3b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs 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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