GW1--00401_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: x f'► i .1
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1.Well Contractor Information:
Robert Teague
14:WATER-ZONES p :,,,
Well Contractor Name FROM TO I iDESCRIPIION•
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2857-Aft. n 1• {ft ft.l I
NC Well Contractor Certification Number
B&K Well Drilling Inc as,OUTER CASING:(for malti_casedWells)ORiLINER(If' -Bcatilt)i> ; .
FROM TO 1, DIAMETER THICKNESS MATERIAL
Company Name 0 ft• ei 3 ft. 61/8 in. SDR-21 PVC •
�� 16:'iINNERCASING OR TUBING°(seotheratal<c3osedkoejiy r
2.Well Construction Permit#: Y )S t� 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.i in. .
Water Supply Well: iZrSCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural ' °Municipal/Public
ft. ft. I in.
QGeothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft. in.
°Industrial/Commercial °Residential Water Supply(shared)
18..GROUT .. ,..
Irrigation FROM TO + MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: _ ft. ft. 1
0Monitoring 0Recovery ft. ft.
Injection Well:
Infer Recharge ft. ft.A
q g 0Groundwater Rcmcdiation
DI Aquifer Storage and Recovery19:SAND/GRAVEL PACK;(rf applicable)
q g °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test 0Stormwater Drainage ft. ft.
°Experimental Technology 0 Subsidence Control ft tt. ;
°Geothermal(Closed Loop) Tracer
FROM TO h"dddltl0a9l'Sh¢t51"f:tlCCSrY).:�':: � .:..'-;..'
20:DRILLING'LOG(attac „_. ,
0 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) DESCRIPTION(color,hardness soil/rock type,grain size etc.)
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4.Date Well(s)Completed: 1 lii),5 )4 ell ID# 0 ft a ft. 4:41 p ii o_I
Sa.Well Location: ft LO tft' L A GI-L�fLl P.
�c't-(-1 It/T (pa.N <.V ok ft ft. ; /�� la
Facility/Owe/NNa�amee Facility lD#(if applicable) ft. ft. '`F-•sy 3-'"a -.y
��''0 �NCtt,1G_- -T 1 ft. ft. 1"."''al .► ,� )
Physical Address,City,and Zip 7 ft. ft. J/4 N 1 , 70?
kkr.in die‘---" 006.3 0/3 :21:1ZED•IARKS.;;, .. .::.
County Parcel Identification No.(PIN) ' tthJi.>:F.t•,,,c°i ,.",w.g4•
+z1 U.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification {
N W I' ,
6.Is(are)the well(s)i§Permanent or Temporary Signature of Certified Well Contactor Date
By signing this form,1 hereby'certify that the well(s)was(were)constructed in.accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or 115,4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature alike copy of this record has been provided to the well owner.
repair under#21 remarls 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 1 W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
7 v 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 tfdifferent(example-3@200'and 2@100)
construction to the following: .
10.Static water level below top of casing: 40'
If water level is above casing,use"+•• ( ) Division of Water ft. Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: �ln 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:
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t VV Method of test: Air Flow 24c.For Water Supply&!lniection Wells: In addition to sending the form to
Chloe Tabs 1 11z Lbs I the address(es) above. also'submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well constn:ctton to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water R!ources Revised 2-22-20i 6
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