GW1--08079_Well Construction - GW1_20231215

i4� WELL CONSTRUCTION RECORD(GW-1) °
6PFor Internal Use Only:
V 1.Well Contractor Information:
Robert Teague
Well Contractor Name '14'VATER'.ZONES'• '_.. „FROM 4! TO.
l;
2857-A y�U e• +Lit ft" DElscl Prlon
NC Well Contractor Certification Number // ft. ft. I f
B&K Well Drilling Inc •is:'OUIER CASING.(formuttf ca'sed-rells)"OR:LIhIERFda ' ca61e)
. .
FROM i^T�O� DIAMETER THICKNESS MATERIAL
Company Name 0 ft / ft I 61/8 in.
` I(N�` SDR-21 PVC
2.Well Construction Permit#: �p� - �1 [� '46�R`CAS G OR'£UBING(geothertiial closed3
FROM TO DIAMETE • ••-
List all applicable well construction permits i.e.UIC,County,State.Variance,etc.) THICKNESS MATERIAL
fL ft. in.
3.Well Use(check well use):
ft. ft. in.
::17:SCREEN
Agricultural °Municipal/Public FROM TO DIAMETERin
it Geothermal(Heating/Cooling SLOT SIZE
111 Water Supply Well: THICKNESS MATERIAL
Supply) ft ft, in
g PP Y) Residential Water Supply(single)
X Industrial/Commercial ft ft. in.
Residential Water Supply(shared)
•hriration 18:GROUP';
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ar ft. ft.
Monitoring Recovery
Injection Well: ft. ft.
a Aquifer Recharge °Groundwater Rcmcdiation ft. ft
Xi Aquifer Storage and Recovery °Salinity Barrier (-8 /GRAVED:PACK(ii applicable}.-:
Aquifer Test p�, FROM TO MATERIAL EMPLACEMENT METHOD
IStormwater Drainage ft. ft.
I Experimental Technology OSubsidence Control
ft Geothermal(Closed Loop) 0 r Trace ft. ft.
20:•DRlLL•LNG TAG{attach idditional stieetilf necessary}
Geothermal(Hearin.Coolin_Return) ■;Other(explain under#21 Remarks) FROM TO '"
DESCRIPTION(color,6ardne. so _rainy e+ sIIII
4.Date Well(s)Completed: `!Z ell ID# ► � —
5a.Well Location:ik, ��='�_�'�
ft. _ - _
� ,tom C �M ft.
Facility/OwnerIIIIMIII
Name �` J
Facility ID#(if applicable) ft ft ti:: •• ,• y
{/ 'e � ft. ft.
Physical Address,City,and Zip
I ��--err ,
)t NC_Pl� >•21 ft. ft.
> Zi:I2E1ti1hRT{S' i ,+
County
Parcel Identification No.(PIN) Q:'v k;'1 ^�^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certifica•
N W ,r
6.Is(are)the wells) permanent or Temporary Signature of Certified Well Contractor `-6—i6 --�r
Date
Yes orNp By signing this form,I hereby c•ert fp that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:
If this is a repair,fill out known well construction informa[in an explain the nature of the copy tfthisrwith 15.4 ecord has been pro I 5.4 Iv v ded to th CAC�well nC �erV ell Construction Standards and that a
repair under#21 remarks section or on the back of this form.
agram or
l
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Sited use the back of this apage ito provide additional well site details or well
construction only1 details: .
You may
is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
For multiple wells list all depths/fd(fferent(example-3@20'and 2@I00) (ft) cons For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:40 construction[o the following:
If water level/s above casing,use"4-" (ft.) !
Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1 M 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.) I ,
24b.For Injection 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:
(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 SuD�ly&lniection Wells: In addition to sending the form to
13b.Disinfection type: Chloe Tabs t tlz Lbs the address(es) above, also submit one copy of this form within 30 days of
Amount: 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