GW1--01840_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,. .' 3 ;;s
Well Contractor Name FROM TO DESCRIPTION
2857-A Z a-V- .13 aft. 1$f /t 2iv1
L ft. 27 oft.
3 6 (`/o,"
NC Well Contractor Certification Number AS:OrER CASSING(for iaultf sed4elts)OR ETNER'(ff' Seab1 ,
B&K Well Drilling Inc FROM TO I DIAMETER THICKNESS MATERIAL
0 ft. S ft. 61/8 in" SDR-21 PVC
Company Name
1 _ �\ 1 2 16::INNER:CAS ORTUBING'(Odtbertnafelased-ioop):; •, .,..,::�;.;%.:
2.Well Construction Permit�Ith1�$ v� t• v_ 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.
17.SCREEN :.,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipal/Public ft. ft in.
0 Geothermal(Heating/Cooling Supply) PDResidential Water Supply(single) ft ft, in.
0Industrial/Commercial OResidential Water Supply(shared) :1ti:GROUT
IlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT I
Non-Water Supply Well: ft ft
. 0Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
0 Aquifer Recharge DGroundwatcr Rcmcdiation
19 SANDIGRAVEL'PACK.(if-applicsble) :• .
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence• ontrol ft. ft.
Geothermal(Closed Loop) OTracer 20:.DR1L7:LNGLCIG;(attachadditioualsheets:,fiteeeffiit3) :ii .: ' :
FROM I TO DESCRIPTION(color.hard soil/rock ape,grain size,etc.)
DGeothermal(Heating/Cooling Return) 00ther(explain under 1 Remarks) ` ft. 5- ft. -}
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4.Date Well(s)Completed:V i. GJ Well ID# ft. ac3 ft k e>.,,,..
�}5a.Well Location: 1J 1 p �/�/ b Sft 3 G 5 ft.'k G'•-' u-'`�
C..0- r I't �il i L elm th t)` 4/r -"ft. f.. I'
Facility/Owner amc • Facility ID'(if applicable) ft ft. 1 't,L:Ls"L f. ‘I C.,Li
3(1 ) J'7SNr-N o Vs L-./ ft. ft. MAR 1 % Z074
Physical Address,City,and Zip 6-,0 ft. ft.
21r'REhLKRK$I1 i , If'a&•••ri. ^il::?•I 5Cbsr,akir 1;i
DVjOIBOG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field.one lat/long is sufficient) 22.Certifi • "r . i
6.Is(are)the we1l(s)01Permanent or Temporary ignature of Certified Well Cont or Date
• 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: D 'es or No . with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information a d e lain the nature o/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 W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
' drilled: -- SUBMITTAL INSTRUCTIONS •
9.Total well de p 1 below land surface: S (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfferent:example-3@200'and 2(4T0-0') construction to the following:
10.Static water level below top of casing: 04 ' (ft.) Division of Water Resources,Information Processing Unit,
limiter level is above casing,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) r 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 constiuction to the county health department of the county
where constructed.
Form GW-1 - North Carolina Department of Environmental Quality-Division of Water,Resources Revised 2-22-2016