GW1--08107_Well Construction - GW1_20231215

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Weil Contractor Information: l
I
Robert Teague 1
14rWATER:ZUNES s! , "i ,1' i
Well Contractor Name FROM TO DESCRIPTION
2857-A Se,ft. r c� ft. I f /in
NC Well Contractor Certification Number Li �t 2-r Cam,ft s ` ,e,
e
:15:.OUTER!CASING(for-miil s �yeps RLINER<(ffg' tkaatile)
B&K Well Drilling Inc FROM les DIAMETER THICKNESS MATERIAL
Company Name • 0 ft. ft. 61/8 I in. SDR-21 PVC
q \i I6.INNER`GASINGOR TUBING:(geotheritial.closed I6oji) ,,:'
2.Well Construction Permit#: a 0`J C`Sl 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
®A Cnitrltal FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Municipal/Public ft, ft. in.
°Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single)
ft ft. in.
°Industrial/Commercial °Residential Water Supply(shared)
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring E3Recovery ft. ft.
Injection Well:
uifcr Recharge ft. ft.
A
q g °Groundwater Rcmcdiation
Aquifer Storage and Recovery Salinity Barrier 19,SAND/GRAVEL.PACK(if applicable) r,
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test DStormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft.. ft.
Geothermal(Closed Loop) °Tracer 20.1DRILLINGLOG;(attachitddltional3heetsifite ..,
cessscy); l_
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness soiUmck type,grain size etc.)
ft. ft.
4.Date Well(s)Completed:I 0--I;— l ID# ft, ft.
i
5a.Well Location: ' ft. ft.
•f'`e PI Ai DWI ft. ft.t'i' L
_
F
acility/Owner Name Facility lD#(if applicable) ft. ft. !�•-
I°ILO Int_roat51.1 )11 etj Zi\i ft. ft. rr,
'Physical Address,City,and Zip ft. ft. DEC 1 to 2023
21sR&MARKS'. . .
County Parcel Identification No.(PIN) :r p,.�"'� F+i'
l3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
4
(if well field,one lat/long is sufficient) 22.Certificatio
N W
6.Is(are)the well(s) Permanent! or Temporary `nature of Cerrific.'Well"C cI r . ' 'D to
_/3_ a
By signing this Arm, I hereby cergft that the weft)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or No with 15.4 NC4C 02C.0/00 or 15.4 NCA•C 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informotIon a d ex ain the nature of the copy re-this record has been provided to the well owner.
repair under#2/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,onlyAl is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
3 SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: OS
(ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdjerent(example-3C200'and 2 tei 100')
construction to the following: i
10.Static water level below top of casing:40
If water level is above casing,use-4-" • (ft) Division of Water Resources,Information Processing Unit,
6 /8 • 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Rotay 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 1
Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs 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-I North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016
.