GW1--01839_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague ',14::WATERZONES ?: .
Well Contractor Name FROM TO 1 DESCRIPTION -
2857-A 1 ,5 lt' 14,D ft.Ls D„, t�1,
ft. ft. TV
NC Well Contractor Certification Number .15.OUTER CASING:(for;multi=cased wells)'ORLINER(if up ticable):
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 fL ft-i 61/8 in' SDR-21 PVC
Company Name
• .) f\� '16.INNER CASING OR TUBING(geothermalcltised loop} •W
2.Well Construction Permit#t �3 _(/ U FROM TO 1 DIAMETER THICKNESS MATERIAL
• List all applicable well construction permits(i.e.UIG County,State,Variance.etc.) ft. ft., in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: :"17:SCREEN ,t, '' ,.r<i :i . , , ; '. .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
tAgricultural ()Municipal/Public ft, ft. in.
()Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
OIndustrial/Commercial Residential Water Supply(shared) ;,IS.`CROUT
'1hTigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring 0Recovery ft. ft.
Injection Well: ft. ft.
()Aquifer Recharge DGroundwater Rcmcdiation
•A uifer Storage and Recoveryr:19.SAND/GRAVEL PACK:(if-applicable) ,i, .:•_ -.;.c -
q g Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EtStormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control . ft. ft.
Geothermal(Closed Loop). DTracer 20:DRILLING LOG(attaitiadditionalslieets if necessary):' . .. .
Geothermal(Heating/Cooling Return) FROM TO DESCRI 'ION(color,hardo .soil/rock h e, rain size,etc.)__
( g! gOther(explain under#21 Remarks) AX` /�'
f Jo, At L U ft.j � 1 r G
4.Date Well(s)Completed: i ' 4'Is`,- ell ID# 3 ci ft. 1 1.-&t,; I_
6—
ft. ft.
5a.Well Location: 1
D ` 1 . LN.6.21 fr. ft.
L V .��/ Y'� ft. ft. -.—
Facility/Owner Name 1 e ,) l Facility!Of(if applicable) .
.../ %3 ,e
ft. ft.
Physical Address,City,and Zip ft. ft. j-i,.i,..;v.." -, V�,Ll
`'♦ h LL.D1 DAGr` ,21iEhARKS ?„, , k, rnh is. .-
MAIN GLUL 4
County Parcel Identification No.(PIN)
ktl`i.;tk:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: P'"" 5(n': l:Rr
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(if well field,one lat/long is sufficient) 22.Certific I�$t,��'t'•n, C.
6.Is(are)the well(s)JPermanent or OTemporary igna urc of Certified Well Cotor rac 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: DYes or No with ISA NCAC 02C.0100 br'ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information an explain the nature of the copy ofthis record has peen,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 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a'A-4\-t (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 2i100) construction to the follo'eitig:
40. i
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"*" 1617 Flail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 1/8 (in.) 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.auger,rotary,cable,direct push,etc.) construction to the folloivillg:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m ,r^� Air Flow i
13a.Yield
(gpm) V 5 Method of test: 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: Chloe Tabs Amount: 1 1/2 Lbs completion of well constriction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Watt r Resources Revised 2-22-2016