GW1--00418_Well Construction - GW1_20240116

•
r /02
• . Pnnlo
Frritr'ztsfri. 1 ��� 3
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14 WATER ZONES i .. •
Well Contractor Name FROMTO DESCRIPTION
L'(�.6 TO c4C ft._",��'..�jr�
2857-A ft. ft. IT j
NC Well Contactor Certification Number
.15.OUTER CASING(for multi-cased Wells)OR LINER(if ap Hcable)
B &K Well Drilling Inc- FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 'ft. (lb ft. 6 1/8 I in' SDR-21 PVC
Q ) y./ 16.INNER CASING OR TUBING(geothermal closed-loop):- '
2.Well Construction Permit#: / / a FROM TO DIAMETER I THICKNESS -MATERIAL
List all applicable well construction permits(i.e.U/C,County.State.Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. in.
Water.Supply Well: • 17.SCREEN : •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
Industrial/Commercial E3Residential Water Supply(shared) 18 GROUT• .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring EtRecovery ft. ft.
Injection Well:
ft. ' ft. '
Aquifer Recharge DGroundwatcr Rcmcdiation
•
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(if applicable) '
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EDStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. it.
Geothermal(Closed Loop) OTracer .20.DRILLING LOG(attach additional sheets if necessary) • •• ....
Geothermal(Hearin Conlin Retum) FROM TO DESCRIPTION(color.hardness.soillroc type.grain size,etc.)
(Heating/Cooling Other(explain under#21 Remarks)
O ft. Lib ft. al r•
4.Date Well(s)Complete 2.2i '" Well ID# f`.-DsS ft. �Yd / _
Sa Well ovation: ` { }V'�'
F1reAt,Ylc 3tA 4 V �b ft. L1^S fL ha, 156 � V�
can �)�� s ��- y.-�j�t.
Facility/Owner Name Facility ID#(if applicable) ft. ft-
Physical Address,City,and Zip ft. ft.
C-G��Lie\,\ �719ef60a / ) 21.REMARKS .1Atv u �0��
County Parcel Identification No.(PIN) tnt•r:rr-'_n 7r '^ LI,^"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tC7fi-' °
(if well field,one lat./long is sufficient) 22.Certificatio ,
N W 7 r
6.Is(are)the wells) Permanent or ry Tem ors 4cnjctiwcctor Date
P
By signing this form.l hereby ce,5t11 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or o with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 iVell Construction Standards and that a
!]Ibis is a repair,fill out known well construction information nd lain the nature oft/a 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .---5.--C—J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3C200'and 2 a 100') construction to the following:
10.Static water level below top of casing:40 .. (ft.
If water level is above casing,use"+" (ft.) Division of Water Resources,information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.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.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1f2I hs 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rcsourccs Revised 2-22-2016