GW1--00459_Well Construction - GW1_20240116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Robert Teague .14.wATERZONES.• 1 '.
Well Contractor Name FROM TO I DESCRIPTION
2857-A 11 0' /S t.''16.
NC Well Contractor Certification Number
15.°OUTERCASING(forimhlti-easad:pv lIWORIANERittini Rcablaj` ;.
B&K Well Drilling.Inc FROM TO t DIAMETER THICKNESS • MATERIAL
0 ft i1 k 61/8 to SDR 21 PVC
. Company Name (�f
�'`�1 // . CINNER'CASI-GOR'TUBING'(gedtheittiLek iiia44011 r
2.Well Construction Permit#: a-_ V id 1 �,l FROM TO i 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'SCREEI�: ::
FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ()Municipal/Public ft. ft. in.
()Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
()Industrial/Commercial ()Residential Water Supply(shared) ;.IBaGROUT
"Irrigation FROM , TO ' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. .
0 Monitoring ()Recovery ft. ft.
Injection Well:
• ft. ft.
()Aquifer Recharge ()Groundwater Remediation
19:SAND/GRAVEL'PACK'(if:appliiable�
()Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ()Stormwater Drainage ft. ft..
()Experimental Technology ()Subsidence Control ft ft.
()Geothermal(Closed Loop) ()Tracer '20:3RILiriPIGI;E;IG(attach'it]ditioiislslteeisif"net�iy) .•.: .:: .. ...
()Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO JESCRIPTION(color,erocs hardness,soil/rock type grain size,etc.)
y ° IL g° ft,, /d, 4\
4.Date Well(s)Completed:1 fD -) 1 93 Well ID# ei 6 ft. o ft.
ft. ft 1
5a.Well Location: J2 s)
Facility/Owner Name ! Facility ID#(if ll able) ft ft. 8 'i 7. .( .9 ,^. �-It,.-.
i e'��`\e j�© iQI1� J"C ft ft.i Jt i�� -/.t a-" .t`
Physical Address,City,and Zip ft. ft, V t Of?4
/ In
a f tir1:,.�iii324
County Parcel Identification No.(PIN) LA C f.Ca
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifrca ,
N W �e. � ' ,10� J9-c)-
6.Is(are)the well(s)01Permanent or ()Temporary
STgnaturc"of Certified Well‘...c..tto;74—'.
r Date
By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information a e 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:
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 QW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'a—K: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iidii different(example-3@200•and 2@I00'- 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 MaillService 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: 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 MailiService Center,Raleigh,NC 27699-1636
13a.Yield(gpm) —1 IQ 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
Chlor Tabs 1 1/2 rbs completion of well constriction to the countyhealth department of the county
Disinfection type: Amount: P eP
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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