GW1--08051_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: SPrttt f.
1.Well Contractor Information:
Robert Teague
Well Contractor Name FROM TO DESCR PPION
2857-A 3$Of° 415 ft' 1- i)hi
ft. ft. '
NC Well Contractor Certification Number
B 15,OUTER CASLNG.(for multi-cased'Wells)ORLINER(iifap.linable):
&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. /I el ft- 6 1/8 In' SDR-21 PVC
16.INNER CASINGOR TUBING eotherm al closed loo
-
2.Well Construction Permit#: 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: s17:SCREEN
DA cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DiResidential Water Supply(single)
ft ft. in.
Dlndustrial/Commercial OResidential Water Supply(shared)
I�hrigation :i18:�GROiIT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. ; i
Monitoring DRecovery ft. ft.
Injection Well:
Aft.Recharge ft. ft
qDGroundwatcr Rcmcdiation
A fifer Storage and Recovery 19:SANDIGRAVEL PACK�(f applicable) .
qu g ry QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. '
©Experimental Technology EtSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ,
20:DR1LI;tNGLOG(attach`ailditionsl3tieeis'rt'ne cecsary)'•;'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color•hardness sot/rock type,grain size etc.)
p ft. /15' d; ri Rac-�. 1
4.Date Well(s)Completed: D�1�`�'Well ID# 1
1 I ft. 3 eS ft' hc..,,.cd /1/c,c. rvk fi l���
Sa.Well Location: 3 (, SLIbft Nor) A Sc r
ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�^ I
'�5- Gi ///c301-)n Ch Uri't2J ft. ft. %F 11\ /i,®:7') 1
Physical Address,City,and Zip ft. ft.
.t^tea +, rls' l.r
21;REIKARKS ;`j
G c tall\ ,' _.
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ID++f,� '"�e�Sia ? li`b4
(if well field,one lat/long is sufficient) �'"" ' '
22.Ce ti /
N W i ' 6-
��� 5
6.Is(are)the well(s)0Permanent or (Temporary Signature of Certified W ontractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ENo with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information a-nd cc plain 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: (fA) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exampl 'e 'and Z.@ qtigd
construction to the following:,
10.Static water level below top of casing: 04 ' (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: 6 118 (in.) 1
24b.For Iniection 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 SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Air Flow
Method of test: 24c.For Water Supply &Iniection Wells: In addition to sending the form to
ChlOr Tabs 1 11z Les 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 Resorts '.Revised 2-22-2016