GW1--00417_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: pr t0:0 .
1.Well Contractor Information:
Robert Teague
14::WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2857-A I/1i)ft. C..1 Q�ft. 6;c
NC Well Contractor Certification Number
ft. > ft,
B &K Well Drilling Inc FRO OUTER.CASING(for tri ed•wells)ORHICK R(tap Heable),:-.t';r
DIAMETER THICKNESS g MATERIAL
Company Name 0 ft' cl�ft• I 61/8. in• SDR-21 PVC
• 16:.INNER CASING OR.TUBING'4geuthermal closed400p)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U!C,County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: •
17.SCREEN'
Agriculigral FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EgiResidential Water Supply(single)
ft. ft. in.
Industrial/Commercial
Residential Water Supply(shared)
IS GROUT Irrigation FROM TO ...,...,:,:•:.,-.:: .::<'. :.,,;.: ;i:;:: ...-..
Non-Water Supply Well: MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
Monitoring DRecovery
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remcdiation ft. ft
Aquifer Storage and Recovery Salinity Barrier 19,'SAND/GRAVEL PACK(if applicable)' • • .,
FROM TU MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. R. i
Experimental Technology 0Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer
20:DRILLING LOG(attach additional sheets if necessary)::,.::;;.
Geothermal(Heating/CoolingReturn) FROM TO DESCRIPTION(color, ness soil/rock type,grain size,etc.)
4.Date Well(s)Completedc1 23 Well 1D# + ft• �S� f• l (
5a.Well Location: "'� - -` hard `` ��-,�C�-�-
1cAmAa MC[,ivri ���ft. zl ft. J.1C� SGL 1 ft. ft
Facilirty/OwnerNamc cility ID#(if applicable) ft. ft. '^:
S3L 6 Z C� ��
) a r\ \ v ft. ft, ' fr "4.-- :,.0, i �ti ("
Physical Address,City,and Zip ` V ft. ft.
�
,JAN 1 6 ?074 •
C 0`C)k,S GV &7 6 7 2i„REMARKS.:::::
l
County Parcel Identification No.(PIN) If1J+'rfrgt D PrC.c x
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: dvvtW- 0
(if well field,one lat/long is sufficient)
22.Certi6 lion:
N W � agf
2_6.1s(are)the well(s)OPermanent or TemporarySignature of Cetified Wcl ontractor '
twasDate
ructed in accordance
7.Is this a repair to an existing well: DYes or o h signingIS.i NCAC 02C.0100 or/54 NCAC 02C.0200Jffell Construction Standards and that a
• If this is a repair,fill out known well construction information and a 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.
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:
6�S SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdrfferent(example-3C200•and 2 t@r 100') on c2 For MI Wells: Submit this Iform within 30 days of completion of well
construction to the following: I
10.Static water level below top of casing:40
If water level is above casing,use +^ (ft) Division of Water Resou ices,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
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 copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �6 Method of test: Air Flow 24c.For Water Supply&Iniectio I W
ells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit lobe copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2 Lbs completion of well construction to the;county health department of the county
where constructed. I
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016