GW1--00422_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ! �Fnnl��
1.Well Contractor Information:
Robert Teague
14s'WATER zoNES ..: 1
Well Contractor Name FROM TO DESCRIPTION
2857-A J $d ft. /�L/ v ft. , ' �� i 2 in
NC Well Contractor Certification Number .�S�t pip Q ft. /��
B&K Well Drilling Inc .15..OUTER CASING(for 1 as.. ells)• R.LINER.(ffap lieable)-
FROM //TO DIAMETER THICKNESS MATERIAL _
Company Name 0 ft. / ft. 61/8 in, SDR-21 PVC
.16.INNER CASINGC OR TUBING:(geoBtermai crowd-loop)-'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
�Agr1CDltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMunicipal/Public ft. ft. in.
0 Geothermal(Heating/Cooling Supply) ®IResidential Water Supply(single)
ft. ft. in.
0Industrial/Commercial
Residential Water Supply(shared)
El Irrigation 18i,GRQUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery
Injection Well: ft. ft.
DAquifcr Recharge DGroundwatcr Rcmcdiation ft. ft.
Aquifer Storage and Recovery �Saliniry Barrier '19.'SAND/GRAVEL PACK(if applicable) -- .
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additfonatsheets if necessa
(Geothermal(Heating/Cooling Return) s. )$ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.k ness,soil/rock type,grain size•eta)
1 o ft. oft. 6/ !"! d 6 c k
4.Date Well(s)Completed —).1—a3 Well ID# /� ) ft. (dam( • ) ,_\ 31 Le
/Well Location: 2.0 5` �)6_ft. A c.r j .4 .6�
if lD y'd Penh a 1-16. 2 \
ft. ft.
Facilipr{ wner a_Name Facility 1D#(i applicable) ft. ft.
Goss-�,? /� �j ' A /� �:= . `�,�,
V! L As)- b rr ` •N) ft. ft. t�„"' '�w,r L- 7 S 1..' `-1
itie 5 a a
Physical Address,City,and Zip C `3 ft. ft. Jp n, I
ccOchw l
� \ o 74 Cr' / f �6e3 0
County Parcel Identification No.(PIN) ffhk :f,r y{`D I�r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: u, G"a, •d 14S:tr
(if well field,one lat/long is sufficient)
22.Certification:
N W
6.Is(are)the well(s)01Permanent or .. Tern ora igna crtificd Well tractor ��
P 17' Date
By signing this form,1 hereby certiii that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15,4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 3
�� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
(ft.) For All Wells: Submit this'form within 30 days of completion of well
For Total
wells listall depths diffurfa(example-3Qa 200'and 2Q100') 24a.construction
to the following:
10.Static water level below top of casing:40
If water level is above casing.use"+ (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Ct nter,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
I
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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
r-� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit 1 one copy of this form within 30 days of
13b.Disinfection type: 1 1/2 Lbs
Amount: completion of well construction to he, county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016