GW1--06535_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD(GW-1) Ci i I S a x'Pnlz poi rIl'
r... ,,..,z: .:-..
For Internal Use Only: �
1.Well Contractor Information:
•
Robert Teague
Well Contractor Name
At:WATER ZONES
FROM TO DESCRIPTION
2857-A ^/L/�,t't.(S6 ft. 0
NC Well Contractor Certification Number v'-7O it• ). 5_ft. /4(�IQi�
B&K Well Drilling Inc .IS:OUTER:CASING(forniultkiiss2w OR:LINER(if.ap'Hcsble):.. i c:...- t.:
FROM TO I DIAMETER I THICKNESS MATERIAL
Company NameI
a ft.
SCE ft 61/8:, in.
SDR-21 PVC
2.Well Construction Permit#: — �/ 76;:INNER CASING OR TUBING;(geothermattknin.looy):::.7:• ;:. ;..;:.:y;: ,..:;
List all applicable well construction permits(i.e.UIC,C ounry,State.Variance.etc.) FROM TO DIAMETER THICKNESS MATERIAL
OCt. GO ft. '/J in. !-fir'e
3.Well Use(check well use): ft P
ft. in.
Water Supply Well: •
i7.SCREEN -,
Agricultural E)MunicipaUPublic FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Coolin Supply) ft ft. in.
()Geothermal(Heatin
g' g pp y) Residential Water Supply(single)
0IndustriaI/Commercial ft. ft. in.
Residential Water Supply(shared)
llIrrigation 18 GRUUT:
Non-Water Supply Well: FROM TOj� ATEERIAL EMPLACEMENT METHOD AMOUNT
Monitoring Recovery Cf ft. j`J ft � i''1(�l
Injection Well: ft. ft. /
Aquifer Recharge ()Groundwater Remcdiation ft. fL
Aquifer Storage and Recovery Salinity Barrier 19,SAND/GRAVEL PACK`(ifapplicable)
Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
oStormwater Drainage ft. ft.
©Experimental Technology ()Subsidence Control
ft. ft.
Geothermal(Closed Loop) Tracer •20.DRILLING LOG(attach additional sheets•if netxs(Geothermal(Heating/Cooling Coolin Return) FROM To sex e,
g Other(explain under#21 Remarks) DESCRI TION(color• mess.soil/rack type,grain size,eta.)
A) ft...56 ft.
4.Date Well(s)Completecq-)).;3 Well ID# 5 b ft. ^ �5ft• ttir,
, , •�e- c
iv L
5a.Well Location: rl ft �C d��ft !f �Ly�/n 1
� 1 r� ftC!S ft n6 ii ��!� ei 'L�
Facility/OwnerNa c I'
Facility IDS'.(if applicable) ft ft
7�c� G �-.}1. y- e-r1 its f
Physical Address, and Zip II 11 + %•z .. ;.t
�t/,� �(�s,City, ft. ft.ft.
• ...., Az..r ;,: g-,, t•
z1.:RENI>Rlcs 1 M N. 20Z�
County C C T
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1f"f`�^'�' '-f`.,,,,;`^�', ' n(if well field,one lat/long is sufficient) 3�:fi.q
22.Ce 1 "�-
N W • i
6.Is(are)the wells) Permanent or ()Temporary ignaturc o C Certified Well ,,,,e or q.-) `c-3
Data
7.Is this a repair to an existing well: Yes or ey signing this form,/herein cerJv(hrrt Ihc•rrr/!(c)n¢s(were)constructed in accordance
o with ISA NCAC 01C.0l00 or 154.NC AC 01C'.0100 Well Carstruction Standards and that a
If this is a repair,fill out known well construed° in motion an lain the nature oldie
copy of this record has been provided to the well owner.
repair under#2/remarks section or on the bac 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well dep below land surface:
For multiple wells list all depths ifdifferent(example- @200•and 2@l00') 24a.
(ft) For MI Wells: Submit this form within 30 days of completion of well
construction to the following: i
10.Static water level below top of casing:40
Ifwater level is above casing,use••+•• (ft) Division of Water Resources,information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
II.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 CO 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) L 6 Method of test: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs the address(es) above, also submit lone copy of this form within 30 days of
completion of well construction to the,county health department of the county
where constructed. l
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016