GW1--08056_Well Construction - GW1_20231215

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WELL CONSTRUCTION'RECORD(GW-1) For Internal Use Only: ,�M'
1.Well Contractor Information:
Robert Teague
14:WATER ZONES • '' .•..•-
Well Contractor Name FROM TO P DESCRIPTION
2857-A $( fL ?.co U ft .,G,n^
NC Well Contractor Certification Number 956 fL 'O fLf
d p".
B&K Well Drilling Inc 'la:VUT RCASINGt(fohn � ):OR, ble> •,,. •
FROM f4 I� 6 V L 'DIAMETER THICKNESS MATERIAL
Company Name 0 61/8 in' SDR-21 PVC
16::INNER CASING ORTUBING:(geothermal cieseii400py'2.Well Construction Permit#:'1aa 3 — a 0 a C1s 7 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.
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Water Supply Well:
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
Indust ft ft. in.
Residential Water Supply(shared)
IS..GROU1
Irrigation FROM TO ' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery
ft. ft.'
Injection Well:
Aquifer Recharge DGroundwatcr Rcmcdiation ft ft.
Aquifer Storage and Recovery .19.SAND/GRAVEL PACK(if applicable) .
rY E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.,
Geothermal(Closed Loop) Tracer
� 2o:nRua:rNc:LOG:(seticl►aaateonsiIs>ieeb:ifnietsiaryV Y.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO ! UESCRIPTION(color.hardn il/rock type,gram size,etc.)
Completed:Well(s) Well ID# Le
c•+�ft. r1 a I` ` ,j�I�J /1 ct f CI J!7 cQ.11 III e
5a.Well Location: ao5 fL��s ft. �
J;Il ` S f CPC
La ice. Yfl r► Uet c_4�i0Yl ft. fft. +
Facility/Owner Namc
C� �T/v^' �• /^/Facitit`yl1D�#(ifapplicablc) �yJ] � ft. {";�'�� ^--� .-�
23 v 1 V;Sl a. vi Gtu) 1,+ J/i ti lis 167 ft. ft. r .�Bz 7 pw;a �.
Physical Address,City,and Zip ft ft.
DEC •
Gckai.1 IJ REIGIARKS 1 ��
County Parcel Identification No.(PIN) IriOi^rr^,.�(c:;) �..�l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I Gob t.5 L—}s-y
(if well field,one lat/Iong is sufficient)
22.Certific • i
N W
, l- al, -3
6.Is(are)the well(s)01Permanent or DITemp racy Si aturc of Certified Well Con ctor i Date
By signing this form,I herehv certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: DYes or No with ISA NCAC 02C.0100 or,1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information nd plain the nature(tithe 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:
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: L(
For multiple wells list all depths ifdiiferent(example-3@200'and 2@100') (ft.) 24a. For Al Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40.
If water level is above casing,use"+If Division of Water Resources,information Processing Unit,
6 ,�/8 ( 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ,n
) 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 Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) �� Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabsthe 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 cons[i cl]ion 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 Resources
Revised 2-22-2016