GW1--08057_Well Construction - GW1_20231215

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
-"A Robert Teague
tit.WATER ZONES I'. ,.._-_-
FROM TO 1
Well Contractor Name •DESCRIPTION
2857-A // 0 ft. I!s ft aU
ft ft.l I >
f NC Well Contractor Certification Numbcr
15.OUTER CASING(for multi-cased ivdls),OR`INER'(ri'ap'$cable):,'.c: ; ;.
B&K Well Drilling Inc FROM TO I ;DIAMETER THICKNESS MATERIAL
Company Name 0 ft ft' 61/8 rn• SDR-21 PVC
_ _ i ^Q //ss '�1S.:INNER:CASING OR TUBING,(geothernial closed=loop)- : _ �.�
^
2.Well Construction Permit#• ,121 ! y C FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. IC County.State.Variance,etc.) ft. �f r J� ft' in.
3.Well Use(check well use): ft. s ft.; in.
Water Supply Well: cl7.SGREEN:;
A Cultural FROM TO ,DIAMETER SLOT SIZE THICKNESS MATERIAL
DMunicipal/Public ft.
ft. : in.
['Geothermal(Heating/Cooling Supply) EliResidential Water Supply(single)
ft ft in.
0Industria1/Commercial ['Residential Water Supply(shared)
18.GROUT
[�Irrieation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
DMonitoring Recovery ft. ft.
Injection Well:
DAquifcr Recharge DGroundwatcr Rcmcdiation ft. ft.
©IAgtlifer Stooge and Recovery Salinity Barrier FROM
19.SAN.D/GRAVEL'PACK(irapplicable)-. ,,,; ,,.,;
FROM TO MATERIAL EMPLACEMENT METHOD
E3Aquifer Test DStormwater Drainage ft. ft.!
DExperimental Technology EiSubsidenee Control ft. ft.
DGeothermal(Closed Loop) OTracer
ZtI::DRILI:ING LOG'.(attachsddifiooafstieetsif"uemas+uy) -<' ..� ..
DGeothermal(Heating/Cooling Return) ®IOther(explain under#21 Remarks) FROM TO rD'ESCRIPTION(color.hardness soiVroel e,gram size etc.)
4.Date W,eli(s)Completed: ll ,2- ,3 Well 1D# 0 c a ft. v I r �` iied
p ft. � {�-� fir,,.,•f s
5a.We^ll Location: �+ ft ft.. ��
,�V /G.,�) 11 J1 u) ) ft ft.
Facility/Owner Name Facility ID#(if applicable) ft fty
??7C \ s /eJ f Va1't t �'�_� =�,
PhysicV Address,City,and Zipt ft. ft. DEC 1 t- 70I-3
C��..• C rJ
rA ('�f. o\ 2Li,REMARIC&'.`` .,. :.•.
County `—'�V" 't sn.s t
Parcel Identification No.(PIN) r3 5 .y,,Th l.P�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio
•
N W q
�1 /to
6.Is(are)the well(s) Permanent or Temporary tgnaturc of Certified Wel ontmctor Date
By signing this form.I hereby 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 A100 o'r,1);iA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatio an explain the nature of the copy ofthis record has been prided to the we//owner.
repair under#21 remarks section or on the back of this form. i
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 1 W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
-
9.Total w epth below land surface: ` (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths.ifdifferent(example-3@200'and 2@a 100')
construction to the following:
10.Static water level below top of casing:40' (ft.) Division of Water,Resources,Information ProcessingUni
If water level is above casing,use"_" t,
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
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 Y: Division of Water Resotrces,Underground Injection.Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a v Method of test: Air Flow
WELLS ONL 24c.For Water Supply j Injection Wells: In addition to sending the form to
Chloe Tabs the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: t 1/z los completion of well construction to the county health department of the county
where constructed. II
Form GW-1 North Carolina Department of Environmental Quality-Division of Water1Rdsources Revised 2-22-2016