GW1--00413_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only::
1.Well Contractor Information: I'
Robert Teague
14:WATER ZONES
Well Contractor Name FROM TO 1 DESCRIPTION
2857-A L Gut. /1 r ft,�,f 6 ,,...
NC Well Contractor Certification Number �
35 O ft. 3 ft,;, f'
11 OUTER CASLNG(for: ulti d weg)ORLINERIff ap ticable)
B &K Well Drilling Inc FROM I lTO7
I. DIAMETER THICKNESS MATERIAL
Company Name 0 ft. ft.,' 6 1/8 in, SDR-21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop) . :
2.Well Construction Permit#: FROM TO I 'DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft.; in.
3.Well Use(check well use): ft. ft-,I' in.
• Water Supply Well: 17.SCREEN
FROM TO iDIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipal/Public ft. ft. ' in.
DGeothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft ft. in.
()Industrial/Commercial DResidential Water Supply(shared) . 18:GROUT
nItrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.I
()Monitoring ()Recovery ft. ft.,
Injection Well:
ft. ft.'.
()Aquifer Recharge ()Groundwater Rcmcdiation .
())Aquifer Storage and Recovery ()Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) ' • '
!mil' tY FROM TO . MATERIAL EMPLACEMENT METHOD
()Aquifer Test DStormwater Drainage ft. ft.:
DExperimental Technology )Subsidence Control ft. ft.'
Doeotheimal(Closed Loop) ()Tracer 20.DRILLING-LOG(attach additional Sheets if necessary) . ,
DGeothermal(Heating/Cooling Return) FROM TO ' DESCRIPTION(colort. ,hard sail/rock hype,grain size,etc.)
( g [Other(explain under#21 Remarks) ces ft Cr 1 ft; C , 6, _`
4.Date Well(s)Completed:7 '�'� Well ID# `� '7ft• rJ �
D.d •i hc�, �C,.Y�
Well Location: � ,9 ` • 13 4 CI.1 c r_� 4 G
ft, , ft.i
r �o Yt J r0L- v✓
Facility/Owner Name Facility ID#(if applicable) ft. ft.' j^ .* �.,
ft. ft.' ��-� �L
GOP )O dA Fa11S jd Tor5(,.h� i ft. ft. t ii
Physical Address,City,and Zip . � L.,/ j N •I G 2024
13 v r IRS ( 21.REMARKS
Count ) ' Infori!,,PAtica tPr•_^„NN.7.t3�1tre
Y Parcel Identification No.(PIN)
> I DWQ 301.3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one latilong is sufficient) 22.Certifi tion:
N W , 7.. 3 -D ?
6.Is(are)the well(s)01Permanent or ()Temporary ignature of Certified Wci ontractor Date
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dBy signing this/firm,1 hereby curtifti'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or
o with l.iA 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 and-etpp in the nature nl•the copy of this record has been provided to the well owner.
repair under#2l remarks section or on the back of this form.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You!may also attach additional pages if necessary.
drilled: is-- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 r@200'and 2 a 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.) C
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 dopy 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) l 6 C5 Method of test: Air Flow 24c.For Water Supply'&Injection 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 construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Wate'Resources Revised 2-22-2016
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