GW1--08114_Well Construction - GW1_20231215

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only;:
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1.Well Contractor Information: I
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Robert Teague 14.WATER ZONES .1 I•
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Well Contractor Name FROM TO I DESCRIPTION
2857-A /S et. J G pft.I t G f
15 v ft. 9,`S ft.I�9 � A,
NC Well Contractor Certification Number 15.OUTER CASING(for'in?iiltt-caseE wells)OR LINER'(if a licable) .
B &K Well Drilling Inc FROM I DIAMETER THICKNESS MATERIAL
Company Name 0 ft. g 2 ft.P 16 1/8 tn'• SDR-21 PVC
`16.INNER CASING ORTTUBING(geothermal closed-loop):'. •••• ..
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State.Variance,etc.) ft. ft.iI in.
.3.Well Use(check well use): ft. ft., in.
ter Supply Well:
17.SCREEN
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FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in•
QIndustrial/Commercial DResidential Water Supply(shared) 18;GROUT
IlIrrigation . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.,
°Monitoring 0Recovery ft. ft.
Injection Well: ft. ft.
()Aquifer Recharge DGroundwatcr Rcmcdiation
19 SAND/GRAVEL PACK(if applicable). •2 '',•,
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test DStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOGI(attsch additional sheetsif necessary).;
(Heating/Cooling Return) FROM 1 TO DESCRIPTION(color,hardness.soil/rock type,grain size.etc.)
DGeothermalg/ g Other(explain under#21 Remarks) l' ( /r
4.Date Well(s)Completed:'b- .43 Well ID# $'Z ft. 1�3ft.i -C_'r J 131v"',
5a.Well Location: ^^Sft. d ft.',h�rJ ,, (s 1 /)1 l
S c A3 H S u f low d c J ft. • fL . �7--t1 �✓C�
Facility/Owner Name Facility ID#(if applicable) ft. fLi
)2. W i S L ). C) ft. ft: e :�_.4�., �^ '� . ul
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Physical Address,City,and Zip ft. I ft: I I , .- ryR ?
21.-REMARKS 1 t E L :' 2O2 3
Infar,7M:—:: a-.,.,
County Parcel Identification No.(PIN) �_-.. tir,.t
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
D vCi'' :DG.
(if well field,one Iat/long is sufficient) . ' 22.Certification:
N W /V -2- ^a7 tit
6.Is(are)the well(s)0Permanent or oTemporary Si_ attire of Certified Well C ctoa r Date
By signing this fin-in,l hereby cerlifi that the veal was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information an plain the nature of the copy of this record has been provided to the well owner.
repair under#21 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,only I G1 -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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing:40' (ft.)
Division of Water Resources,Information Processing Unit,
If water level is above casing.use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
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: construction to the following:
(i.e.auger,rotary,cable,direct push.etc.) i ,
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
Chloe Tabs 1 tt2 ills
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-1 North Carolina Department of Environmental Quality-Division of Water(Resourccs Revised 2-22-2016
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