GW1--00429_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only;:
1.Well Contractor Information: I I,
t Robert Teague
14:.WATER-ZONES4 ''r, . .., t. . .
Well Contractor Name FROM TO DESCRIPTION
•2857-A (4 tit. l ,ft. .3r 61 yr\
NC Well Contractor Certification Number �.�� oft. /v]�
15l:OUTER"CASING(for mula(,eaSkl•wellayOR LINER(if tip iicabte):;=
B&K Well Drilling Inc FROM TO • DIAMETER THICKNESS MATERIAL
Company Name 0 ft• 7 s--ft. 61/8 rn• "SDR 21 PVC
l:llitS.INNER CASING ORTUBING geothermal closed loo
2.Well Construction Permit#: d.typ-.).C541 6/ 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 .;a
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) Egi Residential Water Supply(single) ft. ft. i' in. '
Dindustrial/Commercial OResidential Water Supply(shared) 180GROUT <, k V"1Irrigation FROM TO' MATERIAL EMPLACEMENT METHOD&AMOUNT .
Non-Water Supply Well: ft. ft.
°Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
°Aquifer Recharge DGroundwatcr Rcmcdiation
• 19:SANDIGRAVEL PACK.(if applicable) _''
Di Aquifer Storage and Recovery OSalinityBamer _FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer ':20i,DRILLING`LOG attacliadditionarsheets if oec " '
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,harrdn)ess soil/rock ty ,grain size,etc.)
b ft. 7S f t. 1 l �,3 C C,... , cs.�
4.Date Well(s)Completed:11- (— ¢-s Well ID# `7 r ft. ztz, eft. o!.,, 0 (,� (�
)Sa Well` Location: e '1 OSft. W��tt. /_Cur(-J V S v'-L'„)�)1?'`
t—• -5 Q D to 1 i v\ ft. ft. ''dd
6 "•. � %
Facility/Owner Name Facility ID#(if a licablc)' ft ft. w + ^^�
36�3 \L U-4 OA c-) .5100OA-S \t' ft. ft. t pp�� �>
Physical Address,
City,( and Zip ft. ft. `��/Y 1 6 907�
,ek,G V„� ':21:.REMARKS's" {th`, �,� r t ` L
rf
County Parcel Identification No.(PIN) . I `1iQf n v w f 2 Uii:P
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field;one lat/long is sufficient) 22.Certification:
N W '.) '1
( ^ 0"
6.Is(are)the well(s)JPermanent or Temporary Signature Certified Well Cont for Date
By signing this form,I hereby certify"that the we/I(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with ISA NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Constnrction 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. i
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back ofthis page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You tray also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.-Total well depthelow land surface: �� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 a 100) construction to the following;
10.Static water level below top of casing:40' (ft.) Division of Wafer�" '
iResources,Information Processing Unit,
limiter level is above casing,use"+" :I
1617 Mail+ervice Center,Raleigh,NC 27699-1617
11.Borehole diameter:.6 1/8 (in.) 24b.For Infection Wells':In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: t
construction to the following:
(i.e.auger,rotary,cable,direct push;etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gprn) 5- Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also'submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 112 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 i Reiources Revised 2-22-2016
i.