GW1--08076_Well Construction - GW1_20231215

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
Pnnt Fc
1.Well Contractor Information: I
Robert Teague .,14 WATER ZONES •iz: . ,_. =:
Well Contractor Name FROMy TO I DESCRIPTION
2857-A
? ft. d G0 ft.
45-p ft. dpurft.
NC Well Contractor Certification Number ,:1 .OUTER CASING(for.'multi-cased Wells).OR'LINER(ff up Itcable)':
B &K Well Drilling Inc FROM TO 1 DIAMETER THICKNESS MATERIAL
0 ft. 7 7 ft. 61/8 in. SDR-21 PVC
Company Name
.�/ /L^ .�16t.INNERCASING OR TUBING'(geothernfalclosed-loop)e. I .
2.Well Construction Permit#:T \_.^ 1" - 0 I 7-s FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction perm is i.e.UIG County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17`SCREEN
Water Supply Well: .. ,
FROM' TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural °Municipal/Public ft. ft. ' in.
DGeothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. I in.
DIndustriallCommercial °Residential Water Supply(shared)
}Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring E3 Recovery ft. ft.
Injection Well: ft. ft.
13Aquifer Recharge 13Groundwater Rcmcdiation .
19.SANDIGRAVEL PACK:(ifapplfcable) '
0 Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
®Experimental Technology E3 Subsidence Control ft. ft.I
()Geothermal(Closed Loop) DTracer ,20:.DRILLING.LOG(attiehadditionalslieetsifueeessary) ' ., _.
QGeothermal(Heating/Cooling Return) FROM TO I' DESCRIPTION(color,hardness.soil/rack;rain size,etc.)
( g/ g gg Other(explain under#21 Remarks) O ft. 77 ft.. (i r i 4 J��c',(
4.Date Well(s)Completed:! I ' I?-X ? Well ID# 27 ft. 5_5.,h(A0' I c-e rwn.
5a.Well Location: r1 6 t —3�ft 1 a!"J -C �t
O'er t. ft. J1 ` �( ! t
Facility/Owner Na \ Facility lD#(if applicable) ft. ft. t."' r--, : -' e'17
N7kt �Y ! CJ V 41- ft. ILI ., .., •. .i. ; i.� 47:
Physical Address,City and Zip ft. ft.1 DEC i, 5..
?Q2
3
L. 1 h GOI rc�Cp r 21 REMARKS `' - 1
I Infor,zr n ? ,
County Parcel Identification No.(PiN) I. r :1 t F a 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer'rc on: _
N W 1 I —'I 3 -41---?
6.Is(are)the well(s)OPermanent or OTemporary ignature of Certified Well Cont r Date
...����aa##!! By signing this form.1 hereby cm.*fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or y No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information,ands,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. 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 GW-I-is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
® SUBMITTAL INSTRUCTIONS
9.Total well pth below land surface: (11) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'an 2@100') 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 Infection 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
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 0 Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well constriction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016.