GW1--00426_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: „ { EF7 '
1.Well Contractor Information:
Robert Teague
14:WATERZONES: : :I•.I .
Well Contractor Name FROM TO I I j DESCRIPTION
2857-A e, Oft. t1'oft.' "1 c'
ft. ft.l ! "
NC Well Contractor Certification Number
B&K Well Drilling.Inc ,15.OUTER`CASING,(for,;malt-cased welts).OR t NER(Ifap liable) .:.
FROM TO DIAMETER THICKNESS J MATERIAL
Company Name 0 ft' .7C) ff• 61/8 in' SDR-21 PVC -
16:INNER CASINGOR TUBING(geothermalielosed400pyl
2.Well Construction Permit#: ..ba3— I 7j SL,/! ' 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: 17E:SCREEh
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural 0Municipal/Public ft. ft. ; in.
°Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft. ft. in.
QIndustrial/Commercial OResidential Water Supply(shared) ,
111;GROUT i
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - ft. ft.
0 Monitoring Recovery ft. ft.
Injection Well:
utfer Rechargeft. f.
A
q °Groundwater Rcmcdiation
'19.-SAND/GROVEL•PACK-(Ifappiieable)
`
°IAquifer Storage and Recovery °Salinity Barrier FROM TO ' MATERIAL EMPLACEMENT METHOD
°Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) Tracer C - - . ). :.:
20iDR113;I14G°LE7G attach addttrodaisheefs'if ne
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,,6a so ck type,grain size,etc.)
G ft. �� ftelejt
4.Date Wells)Completed Well ID# Oft. +� �y fit. 1Well Location: t. ¢L�/.ft. J L
�;� fr ft.
Facility/Owner Name ', JJ Facility lD#(if applicab e) ft. ft. .~" "',1„-.
Lb SS r lilt- OU h- .i..�, F-�-.-.[,,
+ ""•Physical Address,City,and Zip ft. ft. A N 1 6 2074
l O `)'-' 21:.RER$ARKS
County Parcel Identification No.(PIN) ti 'l'tt•.i URN i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific 'on:
N W �`
6.Is(are)the well(s)01Permanent or DTemporary Signature of Cad,cd Well Contractor )Date iQ
By signing this form,1 hereby certify 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 d lain the nature of the copy of this record has been priwided 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 GW-1 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: (ft) 24a. For All Wells: Sub[tit this form within 30 days of completion of well
For multiple wells list all depths/fd(erent(example-3@.200'and 2C100)
construction to the following:
10.Static water level below top of casing:40 ft.
If water level is above casing,use"+ ) Division of Watel( r Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) I
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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2/ Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1/2I bs 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. fI
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016