GW1--08078_Well Construction - GW1_20231215

• I !i
WELL CONSTRUCTION RECORD(GW-1)
For Internal Use Only:
1.Well Contractor Information:
Robert Teague
;`14.WATER-`ZONES: ,v) ' ,-
Well Contractor Name , ,<
FROM TO DESCRIPTION .... '
2857-A ft ft.
NC Well Contractor Certification Numbcr ft. ft.
I
B&K Well Drilling Inc FROM
xERcaslrtc(rormwa ETER usyol HICKNESS ' 'x�aATE
FROM TO I DIAMETER I THICKNESS MATERIAL
Company Name 0 ft I1 LyI Lift 6i 1/b in•
// SDR-21 PVC
��+1 .3 a ":I6•'INNER'CASING'o t)BING;(geotheimal closed-Ioopj
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) FROM ft TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#�G
ft. in.
3.Well Use(check well use): ft
ft. in.
17:SCItEEty
Water Supply Well:
FROM TO DIAM1tET in SLOT SIZE THICKNESS MATERIALII Agricultural OMunicipal/Public
II Geothermal(Heating/CoolingSupply) ft ft. in
pp y) Residential Water Supply(single)
•Industrial/Commercial ft ft. in.
�Residenria]Water Supply(shazed) ; .
ME Irritation --18:`GROTTY:
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
ft. ft.
II Monitoring Et Recovery
injection Well: ft. ft.
Aquifer Recharge DGroundwatcr Rcmcdiation ft. ft —
III Aquifer Storage and Recovery Salinity Barrier '19 S /GRAVELiPACK da
FROM TO cable =:
Aquifer Test MATERIAL EMPLACEMENT METHOD
DiStormwater Drainage ft. ft
ill Experimental Technology °Subsidence Control '
ill Geothermal(Closed Loop) OTracer ft. ft. �
••:20..DRILLITLV LOG--ittaeli9dd€tionslsheetsifaecessa"
at Geothermal(Hearin:Coofin:Return) U:Other(explain under#21 Remarks) FROM TO
sv/'r�.�yf. DESCRIPTION(color ha ,,ess,smUrock •e, rain size.etc) `1
1 ^^ � ' / Lit.
1 4.Date Well(s)Completed: V"�/.'d,r7 Well ID# ram �
!) ft.
5a.Well ovation: — L'.�
b MEEK - 1Ji _
Facility/Owner Name l `�
Facility ID#(if ap livable) ft ft
•
Physical Address, y,and Zip G ft. ft. ' E m-1�..i;-.T .� i
d ft. ft
- l1, Z1cREMAI2KS " t
County ��— a -
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .` _ ^/r^ r-^^, ,�
(if well field,one lat/long is sufficient) D d i;y'_ '�):
22.Certification:
W ,707-7---- ‘
6.Is(are)the wells) Permanent or Temporary Signature of Certified Well C actor �— 1 G. -,� �
�ee..,,�� Date
7.Is this a repair to an existing well: Yes or No By signing this farm,I hereby cert jy that the well(s)was(were)constructed in accordance
If this is a repair,fill out knox�t well construction information anwith o t NCAC 02C r or si NCAC 02C.0200i Well Construction Standards and that a
repair under#21 remarks section or on the back of this form. plain the nature oJ'the copy of this record has been provided io the well oxuer.
23.
8.For Geoprobe/DPT or Closed-LoopGeothermal Wells havingthe same You •
Site diagramuse the back of this pagelto provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells ma
drilled:____ construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer
For multiple wells list all depths ifdierent(example-3@200 and 2@100� (f4) construction24a. For All Wells: Submit this form within 30 days of completion of well
Static water level below top of casing:40 to the following:
10.Statiter c
ewl a above ing,use of" (ft.) Division of Water Resources,Information Processing Unit,
lf 11.Borehole diameter: 6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.) T ,
Air Rota 24b.For[niech'on Wells: In addition to sending the form to the address in 24a
12.Well construction method: ry above, also submit one copy of Os'form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,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) Air Flow Method of test: 24c.For Water Supply&lniection•Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs 1 1/2 Les the address(es) above, also submit one copy
Amount: completion of well construction t j the county healthsdepartmenttof heform wn 30days countof
y
where constructed.
Form GW-I •
North Carolina Department of Environmental Quality-Division of Water Resources'
Revised 2-22-2016