GW1--08112_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: k:..-...
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1.Well Contractor Information:'
Robert Teague 14 WATER ZONEs..
Well Contractor Name FROM TO DESCRIPTI N
2857-A !yet 15 d ft.. 3a2 i'ill
ft. ft.
NC Well Contractor Certification Number
:15.OUTER CASING(for multilcasedwe1I ORLINER(d'ap` cable).;,
B&K Well Drilling.Inc FROM TO i DIAMETER THICKNESS MATERIAL
Company Name 0 ft ft, 61/8 in' SDR-21 PVC
l 15 INNERCASINGORTUBING(geothint al:elosed400p)
2.Well Construction Permit## t IN) 6 S Re; G FROM TO DIAMETER THICKNESS MATERIAL { v
List all applicable well construction permits(i.e.UIC,County,State. anance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
A Cnitural 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.
DMonitoring °Recovery ft. ft.
Injection Well:
Aquifer Recharge °Groundwater Remcdiation ft. ft. 1
A rfer Storage and Recovery 19•SANDIGRTOEL.PACK(tf applicable) ;;.
4u g ry Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft. ,
Ex erimental Technolog
y gY Subsidence Control ft. ft.
°Geothermal(Closed Loop) Tracer •20:DRIIi1,INGLOG.(attacliadditianais}ieetsifnecessaRy) ' ;.-;;:-..
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
FROM TO . DESCRIPTION(color,hardness.sail/ hype,gram size,etc.)
ft ss ft ; \i ` l
4.Date Well(s)Completed:X•7„1—a Well ID# 55 ft. , 6 5t. ,�J �`l J�j
5a.Well Location: 1 ft. ft.
SK 'tko Il .� 1 V �• ft. ft. ^ �� r . .
Facility/Owner Name Facility.1D#(if applicable) ft. ft. DEC
c `-1 Fp r nt.�I I-1 111 1a ) -4? ft. ft. I 2023
Physical Address,City,and Zip l Iri'C;,.-.;t t)„
\ h � ft ft U '
Z.1 hL'iT v`I�re
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 22.Certification:
N W
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6.Is(are)the well(s)OPermanent or °Temporary Signature of Certified Well ac Date
By signing this Arm,I herehc certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes oNo with 15A NCAC 02C.0100 or 15A NCAC•02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informati an explain the nature of the copy of this record has been provided to the well owner.
repair under#2I remarks section or on the back of this form.
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 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: ao 5
(ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferent(example-3@200•and 2@I00')
construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources If water level is above casing,use"+" ,Information Processing Unit,
6 1/8 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 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 Re lurces,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2a Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also'submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1,2 Lbs completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rcaources Revised 2-22-2016