GW1--00412_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES ..
Well Contractor Name FROM TO DESCRIPTION
2857-A 12g3". - c ft. /P M
/C ft. � ft. (jI
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)ORLINER'(if applicable) `. ....
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS 1 MATERIAL
D ft' V47 ft' 61/8 I , in' SDR-21 PVC
Company Name /
16.INNER CASING OR TUBiNG(geothermal closed loop)'. - ` =
•2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft. ft. j in:
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
BAgricultural DMunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) DEIResidential Water Supply(single) ft. ft. in.
0Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
flirrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring 0Recovery ft. ft.
Injection Well:
ft. I ft.
QAquifcr Recharge DGroundwatcr Rcmcdiation
Aquifer Storage and Recovery ()Salinity Barrier •-19.SAND/GRAVEL PACK(if applicable) -
q g tY FROM TO MATERIAL EMPLACEMENT METHOD
()Aquifer Test DStormwater Drainage ft. ft. i
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer . 20.DRILLING:LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness.sail/rock tape,grain size,etc.)'
a Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. 419 ft.
4.Date Well(s)Completet1' 7.-Z3 Well ID# 1 �1 ft. s 0 e �.lft. h Y, 2 ��
Y
5a.Well Location: 3 Q'ft. 21 iti,sft. Q, ci S & l/G y
sn wc,�'n ccmnrg4. 14 .ft- 4-60 ft.
ft. ft.
Facility/OwncrNamc f`� r Facility lD#(if applicable) ,•„_,
37 15. 0 G c✓ G AK o ft. ft. ' •4.,,..h •k' lit&0
Physical Address,City,and Zip ft. ft. - 1;
G21..REMABK5 r J/�N .1. 6 2074 . .
` Irn;^ ra' 7 County Parcel Identification No.(PIN) ter.'4-.4":1." ",: 1.1,..:1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '3a
(if well field,one lat/long is sufficient) 22.Ce • cation'1�.
N W 4...........1:" 7- 7 --2'�6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Wellll Cont Date
Vex By signing this firm,I hereby cert fv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or i ex with 15.•1 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction information an plain the nature of the copy al'this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. l'
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 dep6 below land surface: .665 (fL) 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'and 2 ro100') construction to the following: 1
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10.Static water level below top of casing:40 (ft.) Division of Water Res urces,Information Processing Unit,
If water level is above casing,use'•+" 1617 Mail Service iCenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
4b.For Injection 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
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Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) I C-` Method of test: Air Flow 24c.For Water Supply&Inie iti in Wells: In addition to sending the form to
the address(es) above. also submits one copy of this form within 30 days of
13b.Disinfection type: Chior Tabs •• Amount: 1 112 Lbs completion of well construction Ito the county health department of the county
where constructed. 1
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016