GW1--00423_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j ? ?' ;`
1.Well Contractor Information: !
Robert Teague
14 WATER;ZONES , :
Well Contractor Name FROM TO DESCRIPTION
2857-A ' C 0 ft. (7 0 ft. A (1 I
•
NC Well Contractor Certification Numbereid oft. .Q-ft• L)(w�7/f,l
B&K Well Drilling Inc 1sa::UUTERCASINIG(formtfti-eased'syells)ORUNER(ifappffeatile)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft' CS. ft' 6 1/8 ; in' SDR-21 PVC
16'INNER;CASING:OltTUBING(geothermal-closed40op) ;..;: ;,
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): fr. ft. ! in.
Water Supply Well:
DAgncuitural FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft ft. in.
OGeothermal(Heating/Cooling Supply) 211Residential Water Supply(single) •
ft ft, in.
°Industrial/Commercial °Residential Water Supply(shared)
184:GROUT ..::'
�"Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
0 Monitoring Recove
Injection Well: ry ft. ft.
A uifer Recharge ft. ft. '
c
q gGroundwatcr Rcmcdiation
®�Aquifer Storage and Recovery Salinity Barrier 19 M�/GRA L.PACK fMapplicable)
T
MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
DExperimental Technology 0Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer
ZODItIi.LLRGIOG(attachaddtttotislsheetsifueeessary);: .; t' ,,...,i ;t;
QGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type>rain size etc.)
�1 �1 b it.Cs ft*-v, ril ko c are
4.Date Well(s)Completed:/—i 1'0 J Well p 3- ft.ks ft. j ( J�/� e
i� i'1 CJ ` jti�'1l�
5a.Well Location:
jS ft. 5 a f ft. 14 81[�-
Facility/Own.erNamc Facility ID#(if applicable) ft f
ft. ft.
Physical Address,City,and Z ft. ft. c L‘-,'B''9 l
Cc46weI r, �: 9 -
2rr:RExIARKs
J l� cG ,(
County Parcel Identification No.(PIN) 24
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lflivr:f�;j�D i�r^ ,� ,„
(if well field,one lat/long is sufficient) ^1 Lt1.z
22.Certifw Lion:-' Irv;•Ci
N W e�l'a f
7— l e a.,,,3
6.Is(are)the well(s)0Permanent or QITemporary , Signature of Certified I Contractor Date
By signing this/inm,/hereby certify that the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes of✓✓ No with ISA 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 an 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.
2 :Site diagram or additional well,details:
u may use the back of this page provide additi to onal well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 'o
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: 0 (ft) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths ijafferent(example-3@200'and 1@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.)
24b.For Iniection Wells: In addition;to sending the form to'the address in 24a
12.Well construction method: Air Rotary above, also submit one copy of thin form within 30 days of completion of well
(i.e.auger,rotary,cable,direct pugh,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Air Flow
Method of test: 24c.For Water Supply&Iniection Wells: In addition to sendingy.iltei,fo.grt to
Chlor Tabs the address(es) above, also submit�otie copy of this form within 30 da ys: .
13b.Disinfection type: Amount: 1 1Iz Lbs 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 Resources Revised 2-22-2016