GW1--00435_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague :14 wATER>zoNEs .
Well Contractor Name MGM T DCRIPrONDESCRIPTIONI
2857-A 15a k. „. k., ,° 5PM,...
ft. k. l I
NC Well Contractor Certification Number AS:OUTER CASING(for tinulti-cased Wells OR'LINER') .(trap Hwble)„ .
B&K Well Drilling Inc FROM TO 1 DIAMETER THICKNESS MATERIAL
0 ft. / / j]ft.I 61/8 in' SOR-21 PVC
Company Name /� t a ,
i V 2 2 ._ q tO y 5 ,16:INNER:CASING�ORTUBING((geathermal closed roop} ;te
2.Well Construction Permit#: 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. ft. to
3.Well Use(check well use): ft. ft. in. .
Water Supply Well: .:.17iSCREEN:*;:. ,< ,,:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural °Municipal/Public ft. ft. in.
DGeothenmal(Heating/Cooling Supply) gaResidential Water Supply(single) ft. ft. in
0hadustrial/Commercial °Residential Water Supply(shared) 18i'GROUT
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
DMonitoring Ei Recovery ft. ft.
Injection Well:
ft. ft.
°Aquifer Recharge DGroundwatcr Rcmcdiation
.19:SAND7GRAVEL PACK(ilappllcable) _
0Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
°Experimental Technology 0 Subsidence Control ft. ft.
DGeothermal(Closed Loop) Tracer A:DRILLINGLOG attach sdditionslslieehilfne
GeothermalClose(Heating/CoolingReturn) FROM TO DESCRIPTION(color,hardn soil/rock pe,grain size,etc.)
Other(explain under#21 Remarks)
�} r1 0 ft. It t, 8 I r1 J ( a
4.Date Well(s)Completed: , 1, 1 v�Well ID# ? ,!,( ft. ?i v L ft. cord !�!4 1k
5a.Well Location: I U ft. /ft. J ���TTT v
/7 r r v k • ft. k.
Facility/Owner Name - Facility ID#(if applicable) . 9�� ft ft. 't f '�'s.�"?1 �.•,
)1 95. --1 Aide-IL 014A/5k/cis— Pr titi ft. fL
Physical Address,City,and Zip pr
41Glh ctia
•21::12EM.41 KS 1i II(hDr ,„; , ,
fa
County Parcel Identification No.(PIN) gt-vAS ('
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22 Ce ''ftcation: 1. .
J y
N W af 1 < L
/I— //7
6.Is are the wells Permanent or Signature of Certified Well C tractor Date ! !
Is(are) ()� ()Temporary
By.signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this:a repair to an existing well: Yes or No with ISA NC.AC 02C.0100 or'1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1( m
GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You ay also attach additional pages if necessary.
drilled: rr �7 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L 6J` (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@100') construction to the following:
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10.Static water level below top of casing:40' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caring,use'•+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) , b 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 1/2 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 Rcources Revised 2-22-2016