GW1--06559_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD GW-I g#jj For+zt
For Internal Use Only:
1.Well Contractor Information:
Robert Teague ,
•.14.-WATER ZONES:• I i ''; r
Well Contractor Name FROM TO DESCRIPTION
2857-A w.,;i.,,•g:.:. >rg—, ) J�Z oft. C2 Sft. Lam,,,_
NC Well Contractor Certification Number ✓ 3/r oft- C g, _
OCTj q /
B&K Well DrillingInc � 1 i1 2023 15..01)IER;CASING(for inuid-Teaa ells OR:L'INER'fifau.liable)'..':".•:.:; ..,:
FROM TO DIAMETER THICKNESS MATERIAL
Company Name rr r
�If3i fu..« l s^Tdh ac�j I�fi 0 ft. [�♦ /tft. 61/6 in. SDR-21 PVC
r'. '- 16.INNER'CAS OR TUBING.(geotheruiii closed4aop)
2.Well Construction Permit#: L P"( 5-9 FROM TO DIAMETER THICKNESS MATERIAL/
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft.
ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: •
17:.SCREEN
�Agicultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DMunicipaUPublic ft ft. 'in.
Geothermal(Heating/Cooling Supply) EiResidentiai Water Supply(single)
IndustriaUCommercial ft. ft in:
•
Residential Water Supply(shared)
riIrrigation iS GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft. '
Monitoring DRecovery
Injection Well: ft. ft.
QAquifer Recharge DGroundwater Rcmcdiation ft. ft.Storage and Recovery Salinity Barrier �`SAND/GRAVEL PACK fif appticablej-
�AquiferTest -
FROM TO MATERIAL EMPLACEMENT METHOD
Et Drainage ft. ft.
DExperimental Technology 0Subsidence Control
Geothermal(Closed Loop) Tracer ft. ft.
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) ZO.:DRILLLVG LOG{attach-add[tioralsheets if neeessaryj.,•;;;..-
FR/OMM /1`(�j/TKO/� DESCRIPTION(color•bardn soil/rock type,grain size,etc.)
ft. '` ` fr (,f 1
4.Date Well(s)Completed G.~�3 Well 1D# y�ft. r. I, t' GCS
5a.Well Location: 1 v < h o-r-J �l 1 ,)C-
y�� l,� ,�r�a ��ft.p J� �ft. �/� yi -Zz5 h 1�U1 " G:�4- fr`�l ft. `'� C�
Facility/Owner Name
f Facility 1DO(if applicable) ft ft.
/2e-LIC-6 h L \/4 C33-0 3 Ler/. c37 D ft. ft. .
Physical Address,City,and Zip ft.
�r� �} I� ft.
214 n` 16 1 7 l 21:REMARKS- :.
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient)
22.CertiFc
N W <=.+"e
6.Is(are the wells c o
OPermanent or Temporary �gnS store of Certified Well Contractor ��
Date
7.Is this a repair to an existing well: Yes orBy signing this firm,i hereby cert is that the well(s)was(were)constructed in accordance
If this is a repair,fill out known well construction informatto nd olain the nature of the copywitt 1 fthSA��eco d hasAC 02C een0 o provir 15.4ded to h Oµl owner.irell Construction Standards and that a
repair under#2/remarks section or on the back of/his m. np
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled:
9.Total well depttfhelow land surface: F' SUBMITTAL INSTRUCTIONS j
For multiple wells list all depths if different(example-3C20 and 22 I00') (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
40 construction to the following: I.
10.Static water level below top of easing: I'
!(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.) I,
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 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 SUPPL�WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,ter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24
c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 t/2 Lbs
136.Disinfection type: Amount: the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed. I
1.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016