GW1--08059_Well Construction - GW1_20231215

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only,
1.Well Contractor information:
Robert Teague 14 WATERZONES -''.j_
Well Contractor Name FROM TO DESCRIPTION
2857-A �5 eft.r�er D ft. I'/6 6 „fr.,
ft. I , r
NC Well Contractor Certification Number L:OUTER CASING(for multi=cased wells)OR'LINER'(if by licable)': ..
B&K Well Drilling.Inc FROM TO a , DIAMETER THICKNESS MATERIAL
0 ft.SO ft. 61/8 in' SDR-21 PVC
Company Name V
*'�� 16:INNERICASING OR TUBING(geotheraialclosed loop)=`
2.Well Construction Permit#:(1{�.cj ^ I %g� FROM TO ' DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. ft.i in.
3.Well Use(check well use): ft. ft. in.
'':17:'SCREEN
Water Supply Well: ���. .. .. :,. • ._ � .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural' OMunicipaUPublic ft. ft. '. in, -
0Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply shared
PP Y(shared) -;�18:'GROUT :_• `
(Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
DMonitoring DRecovery ft. ft.
Injection Well:
DAquifer Recharge DGroundwater Remediation ft. ft.
Aquifer Storage and Recovery Salini Barrier 19,SAND/GRAVECPACK'I(if applicable) :- :'•<- i t
tY FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
0 Geothermal(Closed Loop) OTracer .20:DRILLING LOG(attach additional slieetsifnecessaty):" _ . . •,,F„
Geotherrrtal(Heating/Cooling Return) FROM TO DESCRIPTION(cater, nest.soi/ruck type,grain size.etc.)
( g/ )g DOther(explain under#21 Remarks) T ft.s6 ft.IC) , ,gj_ 15r),h
4.Date Well(s)Completed:(j' L"93 Well ID# 5 0 ft• D.b , J,c \ 12 /, e \�yZ - ,—i- . i
5a..^�W,eellll LLooccatio : y�/� ft ft..
v `v C/ ifs f �'�t�r l`�
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gi t..u[`. Ann 1 n c-- ft. ft.l
tfi Facility/Owner Na c Facility ID#(if apply able) ft. ft. �'Z;1);��p -y�, ( y s f`--,
Physical Address,City,and Zits �` �� ft. ft. �:
21:;REMARKS;; ff1i.. 7r:.: e.;� ;':::
County CCIle�� Parcel Identification No.(PIN) D',Ai0�0t1 LN ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifies
N W R Il-.7
6.Is(are)the well(s)JPermanent or Temporary azure ofC Certified Well C [actor v 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:• Yes or O with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction infornnatio and plain the nature of the copy of this record has heenlprovided to the well owner.
repair under#21 remarks section or on the back of this form. I'
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.Tata th below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(etample-3@200and2@/00) construction to the following:
10.Static water level below topof 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 Infection 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
hlor Tabs 1 112 Lbs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well constntction to the county health department of the county
where constructed. I
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016