GW1--00434_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) i- °
For Internal Use Only:h
1.Well Contractor Information:
Robert Teague
14::WATER'ZONES--'I,
Well Contractor Name FROM TO I I DESCRIPTION
2857-A 2-116 ft.v-S 23 fr' j t/j /�
NC Well Contractor Certification Number 3 . i is tiv
B&K Well Drilling Inc 1s•OUTER CASING(formulti-;caseseedWelts)OR+ ,,- r--,,ti - :
FROM TO I I DIAMETER THICKNESS I MATERIAL
Company Name 0 ft• fe. 61/6 m• SDR-21 PVC
2.Well Construction Permit#: ���. -/ 7am-SS 16:INNNER•CASING OR TUBING'(geotherma{'rhrsedXoo}
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. YLi ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN •.
AgriCUltural FROM TO DIAMETER SLOT SIZE THICKNESS _MATERIAL
13Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) , •
ft ft. in.
Industrial/Commercial OResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - ft. ft.
Monitoring DRecovery ft. ft.'
Injection Well:
Aquifer Recharge DGroundwatcr Rcmcdiation ft. ft.
Aquifer Storage and Recovery -19•SAW/GRAVELPACK•(tfapplicable) .
4 0SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
"ZiiDRIB:INGtfIG.(aftachaddrtronsfsheets'iftiecccsary)'r '.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(co(lor•hardn tVroek type grain size,etc.)
6 ft. C71/ ft. L ^l I i.4. �a4� l 0(Jr,
4.Date Well(s)Completed: s"13 Well ID# ft. 14 Lc)
`� J� i
5a Well Location: a t o S(t `os"i / 5 ��t. j-e.Marlift _ 1
V dr z ft. ft.
Facil
liity/Owner Name Facility ID if pplicable) ft- ft
•
a� C.,O j'L� Y�(J n 1 l � C l(�lj Ar.. ft. beq-,�. ti,.,,,, '•;.4 f:,_ .
a
Physical Address,City,and Zip ft ft t tt N (;
CS1V\Q,1J1 .m...REnmARK. ;" ..1:' J/i ,. t' ylU T
County Parcel Identification No.(PIN) i jth`..,,Al;nfL n 7rr._„ -tt
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (r1 �
(if well field,one IaVlong is sufficient) 22.Certif a' n: ,
N W J-f—&S
6.Is(are)the well(s)OPermanent or Temporary S. a c of Certified Well Con tor Date
By.signing this fain./herehc'cergfj.that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or A o with 154 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 exp ain 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 1 -1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
��� SUBMITTAL INSTRUCTIONS
9.Total well dept Blow land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells st all depths if different(example-3@200•and 2@I00')
construction to the following:
10.Static water level below top of casing:40
If water level is above casing,use"+ Ser(ft.) Division of Water Resources,Information Processing Unit,
, 1/8 1617 Mail vice Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:t 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,m construction to the following:
g tary,cable,direct push.etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' S Method of test: Air Flow 24c.For Water Supply&I Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: 1 1/2 Lbe l
Amount: completion of well construction to the county health department of the county
where constructed. II
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I ;