GW1--00432_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information: I,
Robert Teague ia:wATERzoh]Es l
.
Well Contractor Name FROM TO 1 I DESCRIJ'10(•
2857• -A 7fL`3' t fti I' 4/,/k
fr!
NC Well Contractor Certification Number I
•:•15.OUTER'CASING(for multi=cased wells):OR'L'119ER(sfap"llcable)
B&K Well Drilling.lnc FROM TO I .DIAMETER THICKNESS MATERIAL
Company Name 0 ft' /0 S ft 61/8 in• SDR-21 PVC
rr`` 16:DINER:CASINGORTUIBING:(geothermal'elosed400p}
2.Well Construction Permit aV.)3-J.V 7 FROM TO DIAMETER THICKNESS r MATERIAL
List all applicable well construction permits(i.e.UIC,Cow ,State.Variance,etc.) ft- ft- m
3.Well Use(check well use): ft. ft. in.
Water Supply Well: :17'SCREEh ". ::.,:.•:
QPEA C111111raI FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gri °MunicipalPublic ft. ft. ' in.
OGeothermal(Heating/Cooling Supply) EtRersidential Water Supply(single)
ft. ft. in.
3lndustrial/Commercial Residential Water Supply(shared)
fllrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.()Aquifer Recharge ()Groundwater Rcmcdiation 19:SANDIGRAVEti PACK•da .
Aquifer Storage and Recovery Salini Barrier T
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test 0Stormwater Drainage ft. ft.'
DExperimental Technology ()Subsidence Control ft ft.
OGeothermal(Closed Loop) OTracer .20.:DRlLLING`OG:(attaebsdilitiotiiisheetstf'tiecessaryj:<'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,Hard soiVrvck type grain size,etc.)
p ft. ib3ft { j � ) �
4.Date Well(s)Completed: h.' 1 `‘..�1/il 1D# i V ft- 5 ft- yam / 4,1t-1-L
52-Well Location:, O � Lib .St.1.1�„� �`
— &-.(...)I-- \INI rf\clk.1(54.-r A
Facility/Owner Name FacilityID# a applicable) ft. ft. S'c. w ':^c.
(ifpP ) t 4: ,,./i:- it� r- l
541 t i W n I C e4 c t.Y S\ . C 6 h 61c C r ft. ft. ! , •
1 m tv��' S
Physical Address,City,and Zip ft ft I ~ 1 6 2024
c w,)�.1 �� 21F;REMARKS':i I,. P fri . . . - .
County • •• a,7.7;-
Parcel Identification No.(PIN) NE�L� 2 U4sX i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: j
(if well field,one lat/long is sufficient) 22.Certific Dn:
N W i:�'t'�!'
6.Is(are)the well(s) Permanent or Temporary S. at c of Certified Well Co ctor Date
,.`y By signing this form,i herehv certifp that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or o 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 and plain the nature of the copy alibis 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:d (ft-) 24a. For All Wells:
,, V� Submit this form within 30 days of completion of well
For multiple wells list all depths ifii different(example-C200'and 2@l00')
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.) 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.au er ro construction to the followi i g:,
,g tary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail S!rvice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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 Chlor Tabs 1 1/2 Lbs
tyPa• Amount: completion of well consrvction to the 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
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