GW1--00427_Well Construction - GW1_20240116

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For Internal
WELL CONSTRUCTION RECORD(GW-1) Use Only: I: ----
1.Well Contractor Information: I.
Robert Teague 1
14:WATER"ZONES: 1:
Well Contractor Name
PROM TO I DESCRIPTION
2857-A ! CYt• 1 e' 6 ft; " l e
NC Well Contractor Certification Number ft. ft
B&K Well Drillin Inc 15i OUTER CASING:(foraiulti-cased wells)'ORCINERs(if4-11eable)
g FROM Ito DIAMETER THICKNESS MATERIAL
Company Name 0 ft• ` tt • 61/8 Il• SDR-21
PVC
id:'.INNER,CASINGORTUB1NO:(geatirerma tiosetl-loop}r,. x; . ._
2.Well Construction Permit#:a.t -3-1`(`\I j'1 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.:scREE1v
AgriCUltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�MunicipalPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) MIResidential Water Supply(single)
ft. ft. in.
°Industrial/Commercial °Residential Water Supply(shared)
ri Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT•
Non-Water Supply Well: - ft. ft.'
Monitoring °Recovery I
ft. ft.'
Injection Well:
offer Recharge ft. ft..A
q g E3Groundwatcr Rcmcdiation
®Aquifer Storage and Recovery Salinity Barrier '`19''SANII/ORAVELPACK4(ifdppliiatile) _-
FROM TO ` MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.I
rjExperimental Technology °Subsidence Control ft. ft.;
°Geothermal(Closed Loop) Tracer • 20:.DRILLL'V'G'LOG attaelraddtttonalsheetslfcere�ry)-; •(.
©Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) mom To ' DESCRIPTION(color.hardness-sowrock tfpe grain size,etc.) '
0 ft. 5 ft. N r k vS,
Ko e__)
4.Date Well(s)Completed:I-L l-2. Well ID# q 5 ft. a.6..S ft. h()or) 4, 5 O .)-,/___ v-c,
5a.Well Location: t b qt•?6 5 ft, 56-g-1 f c-c->
In_aCe, tik.11^^ 'Q 1 r 1 6 () ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. __
C7 L13 OA) C Cra 1-i 1� ft. ft. 1,�V
t v ��..0
Physical Address,City,and Zip Li
r ��
f[ ft
C. ok-Ck.) �� al xinrilARus. :: JAN LG2
County 1 5.. e.. 7n-C ParcclldcntificationNo.(PIN) ; fitvexfvw'..^7 N7t,.f9!_+'tcfi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DW 'D 043
(if well field,one lat/long is sufficient) 22.Certification:
N W
91-41 '
6.Is(are)the well(s)01Permanent or Temporary Sign turc of Certified w Contractor Date
By.signing this form,I hereby certify that the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or No with ISA NCAC 02C.0100 or''1SA.NCAC.02C.0200.Well Construction Standards and that a
If this is a repair,fill out known well construction information an explain 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 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: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200•and 2@I00')
construction to the following:
10.Static water level below top of casin 40.
If water level is above casing,use"+" g• (ft.) Division of Water Resources,Information Processing Unit,
6 ,� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /8 (in.) 24b.For Infection 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.) cons[tvetion to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 0 Method of test: Air Flow 24c.For Water Suppiv&11niection Wells: In addition to sending the form to
Chlor Tabs 1 t/z 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. 11
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Rcsourc s Revised 2-22-2016
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