GW1--00419_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only:
1.Well Contractor Information:
Robert Teague g 414 WATE CZtg E5 c t, ` 'i4t;.c.., s .W..1;1k;x :.M 4 ,tKR
Well Contractor Name FRO li(2,,,, DESCRIPTION
2857-A y ft. ft.
•
St. 1 ft. •
NC Well Contractor Certification Number ( •
(
gl15..:OtITEIWAE N, fo il fIti th-cased—*611)1UR'T,1NER flap Hest le)" , i ,,
B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 fts�,. ft. 61/8 , to• SDR-21 PVC
Company Name
1#14NNEire,RING!UR (IMNG•(eothekinaleios iii4a6 j AlIf., . ai
2.Well Construction Permit#: 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. in.
Water Supply Well: 17;SCREEN x M.,m ._� i _, r ;_" :
FROM TO DIAMETER .Ix. w
SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft ft. in.
• Industrial/Commercial DResidential Water Supply(shared) r, s �2 a ,..,
�8 CiR�U�A„!K: �: �,.r,;:= = ....'�;.., t. _�;..:c�d _..r.s,a"` :t:;,.' ;.�,::r...a,;.,??.t
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge OCrroundwater Remediation
719 5AND/GRAVEL,PACICflfapplicable)v MO ' a:z_` .. ' ... tfA Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft. I
Experimental Technology EtSubsidence Control ft. ft.
Geothermal(Closed Loop) Erracer 20 ili1CIL1;INtz,EaG(iitarhaddlt iiiiii tieet3-if=necessary`}, .,h ,;g,>r�W
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hatless,soil/rock type,grain size,etc.)
( g/ g Other(explain under#21 Remarks) Oft ,S e ft �]; Ira )cQ�`
4.Date Well(s)Completed!^Ls 7T3 Well ID# 15 , ft. 50 5ft, 17iNcA,rJ` —4 So-?4 JN—.e
5a.Well Location: ft. ft.
I and Graves ft ft. � r P 'a icy :4
Facilit/O er Nameft. ft.
Y Facility ID`#'(ifaappp_licable)�t. ft. J�1 n' (;
3 .S7�sourne.yS' ent) Wre.ZV1tli1r ft. 1P9 LU 4
Physical Address,City,and Zip ! ft. ft. Int;,,tfn n 7r h ] �
Cr."‘ L t 1 \ ..21 REMARKS,:re:',xr ; , ISIl ttWy,":{e";C r:K W k s'�Z rO�E.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient)
22.C
N W
till's 9 4C. • —I�10�
6.Is(are)the weli(s) Permanent or Temporary ' Signature ofCertifi e�Well Contractor Date
By signing this form,I hereby cent fy 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 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information a d lain 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:
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: D� 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 if-de-crew(example-3@200'and 2@100') ,
construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information ProcessingUnit,If water level is above casing.use"+ 1617 Mail Service Center,Raleigh,NC 27699-]17
11.Borehole diameter: 6 1/8 I
(1A.) 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;foim within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) _ i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1 1636 Mail Service Center,Raleigh,NC 27699-1636
4 13a.Yield(gpm) b 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. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016