GW1--00433_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: L Pcli} '.
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1.Well Contractor Information: j
Robert Teague
14 WATERZONEs , `l> ;< ..:
Well Contractor Name FROM TO I I DESCRIPTION
2857-A ".I I
ft. ft.!
NC Well Contractor Certification Number
B&K Well Drilling.Inc ;:.1S:OUTER CASING'(for multi-cased3eeJk;OR I�R; ;,•
'C�appliMATE;,
FROM WA� DIAMETER THICKNESS ) MATERIAL
Company Name • 0 ft �1—It• 61/8 in SDR-21 PVC
16:INNERCASINGORTJBING(geothermal!;etosed400p} `. :.
aoa3- 'ac)2 1Q
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): ft. ft. in.
Water Supply Well: 17:SCREEN ... , ::
Agricultural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
�Municipal/Public ft ft. in.
°Geothermal(Heating/Cooling Supply) EliResidential Water Supply(single)
fL ft. in.
°Industrial/Commercial °Residential Water Supply(shared)
;18'GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. :
Monitoring °Recovery ft. ft.,,
Injection Well:
utfer Recharge ft. ft.
A
q g °Groundwater Rcmcdiation
®IAquifer Storage and Recovery Salinity Barrier •19•"SAND/GRAVEL,PACE(ifapphcahle)
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test ®IStorntwater Drainage ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) Tracer
-20:13RILI:ING`LOG:(atfacfiaddtGtanstsheets":f'aecw.ry) ''
°Geothermal(Heating/Cooling Return) ©IOther(explain under#21 Remarks) FROM To DhSCRlPTION(color,hardness.soil/rock type,gram size etc.)
4.Date Weil(s)Completed: t6 �3 Weil ID# '1 O ft. NS .I S S....Pc-4
A.Well Location: 1b6 ft. 4 05 ft ha.c-ei- 5, ,K__I`
9 -+� `\ l 1 k- "+l> fL ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. , _ ^�
3 ‘yv Lk31Z, �-1t N 1�t G'\r r ft. ft. .�. h N
.' ,, ift/9C-'"t' 9 r
Physical Address,City,and Zip ft. ft Jib N
'21::REMARICS r: . .I.I '' r
County Parcel Identification No.(PIN) fDs ' nt n prnr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 22 Certif cation
N W j Z 1;� Z
3
6.Is(are)the well(s)0Permanent or EITemporary Signature of Certified Well Co etor Dat
By signing this form.l hereby certify that the well(s)was(were)constructedn accordance
7.Is this a repair to an existing well: DYes or`�/1No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stand rds and that a
If this is a repair,fill out known well construction information and e lain 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
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1"
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 / (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdlfferent(example-3@200'and 2@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 Injection Wells:1 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
•, 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /0 Air Flow '--.. 1 i
Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above, also,subrnit 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.
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Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016