GW1--08113_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD GW-1 ' ''-'%Print`
For Internal Use Only: ,
1.Well Contractor Information:
I
Robert Teague
Well Contractor Name FROM
WATER ZONES • I :..•: •
FROM TO I DESCRIPTION
2857-A MEI/C ft. 1�
NC Well Contractor Certification Number /
B&K Well Drilling inc '•Is.OUTERCA5ells ;fn
ot, oRrINER ,;Ucabte •-•
.
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft.
NMI 61/6 in' SDR-21 PVC
2.Well Construction Permit#: —�� •.16••INNER CASING OR TUBING i .:
FROM :ERheclnahciose$�loo:List all applicable well construction permits i.e.UIC,County,State.Variance.etc.) ® TO DIAMETER
® MATERIAL ,'
3.Well Use(check well use): ft. in.
Water Supply Well: MI ft in.
X Agricultural
°MunicipaUPublic FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
X Geothermal(Heating/Coolingft. ft. in. _--
Supply)PP Y) Residential Water Supply(single)
X Industrial/Commercial °Residential Water Supply(shared) ft ft. in. _
X Irri:ation ••i8.
FROM
® TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
X MonitoringD ft.
Injection Well: Recovery
ft. ft.
Aquifer Recharge °Groundwater Rcmcdiation ft. ft.
11
it Aquifer Storage and Recovery Salinity Barrier 19.SANDIGRAVEG PACIZ:(Ifa ratite . ,
�AquiferTest FR® TO •MATERIAL EMPLACEMENT METHOD
0 Stormwater Drainage ft. ;
E Experimental Technology
Subsidence Control ft
E Geothermal(Closed Loop) °Tracer ft
Geothermal(Hearin_Coolin_Return) 20..DRILLINGLOG attach additional sheets if
Other(explain under#21 Remarks) FROM TO �jD SCRIPTION(color.hardness. oiVrock .e,:rain size,etc.)
4.Date Well(s)Completed: i,� Well ID# M�_— Q C-•
5a. 82111
WellLocation: �mil
W I_� �, ~
MIMI
Facility/Owner Name Facility IDS(if ft ft •
3
ft. ft.
Physical Address,City,and Zip :>,-- 'I,—T .1 1-J
R �� ft. ft. IMIIIIIIIMIIMEIBNNI
4�_l_i_]. 21rREMARKS
.•,-,.County
Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Cell' lion•
N
W A�
6.Is(are)the well(s)01permanent or °Tern ora `
L p p ry ignature of Certified Well C j ctor 1 t -` ��
Date
7.Is this a repair to an existing well: °Yes or By•signing this form,l hereby certify Athan t2he well(s)see(Here)constructed in accordance
!Phis it a repair,fill out known well construction injormatio and Nn ain the nature glaze
copy oft/r Ceco has been provided to he well Her. l C.ousrrucrion Standards and Thar a
repair under k21 remarks section or on the back of this form.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Site diagram e the ba k of thisal a elto provide additional well site details or well
construction,only is needed. Indicate TOTAL NUMBER of wells You mayP g P
drilled: 2 construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: J�I SUBMITTAL INSTRUCTIONS
For multiple wells list all depths tfdifferent(example-3 a.200 and 2@100� (ft') construction24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:
40. to the following:
If water level is above casing.use••+ (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1/81617 Mail Service{Center,Raleigh,NC 27699-1617
Air Rota (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ry 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY
1636 Mail Service',Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow
24c.For Water Supply&Injection Wells: In addition to sending the form to
13h.Disinfection type: Chlor Tabs 1 1/2 Lbs the address(es) above, also subrnit one copy of this form within 30 days of
Amount: completion of well construction Ito the county health department of the county
where constructed.
Form GW-I r
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016