GW1--01859_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,
1.Well Contractor Information: 1
Robert Teague 14:WATER'ZONES - •i .. y - - -
Well Contractor Name FROM TO I !DESCRIPTION
2857-A .27 is. 2 g0 ft.I t, (e M
ft. ft.I
NC Well Contractor Certification Number
15,OUTER CASING(formulthcasedwells)'_ORIANER(if lip licalile)
B&K Well Drilling Inc FROM TO ' '!DIAMETER THICKNESS MATERIAL
0 ft. 3 V ft.' r 61/8 m. SDR-21 PVC
Company Name l/
16:INNER CASING OR TUBING.(geritherutal closed loop):'.: ., ,•' +`_: ;x
2.Well Construction Permit#: 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. •
ter Supply Well: •3 TO DIAMETER SLOT SIZE THICKNESS
FROM 7.SCREEN ... ,,-.; -ESS MATERIAL
/.
Agricultural DMunicipal/Public ft ft. in.
0Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
jIndustrial/Commercial Residential Water Supply(shared)
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.,
)Monitoring D Recovery ft. ft.'
Injection Well:
Aquifer Recharge DGroundwatcr Rcmcdiation ft. ft.
r19:SAND/GRAVEL PACK(if applicable) ,.
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test 0 Stormwater Drainage ft. ft.l
DExperimental Technology 0 Subsidence Control ft. ft. ;
II0�Geothermal(Closed Loop) Tracer '20.DRILLING LOG attach additional sheets If aieces
0 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To i !DESCRIPTION(coClor_hardness,soil/rock type,grain size,etc.)
p / ft.: ft _\s � / ..
4.Date Well(s)Completed:[* -3 ' ,r Well 1D# `3 0 ft:4x c• ft. (J
5a.Well Location:.C�'i. a 6 SH_j C5 Jt' A aeti , 5C1• 1. �,
w t, .AV! pe-� e/ ft.` ft.
Facility/Owner Name Cr', 1 ` Facility lDO(if applicable) - ft. ft.
1 3 C C s a Y\ �A 0h1.% CI ,ic j ft. ft„
Physical Address,City,and Zip ft. ft
6t�s 0 '21::REMARKS._ I.:"` .. ..l..2 n w?. • ,i s-"' �. �..
County Parcel Identification No.(PIN) ! .
MAR 222024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif 1, on
N W llifr'C; 043 f Fail
6.Is(are)the well(s)jPermanent or E3Temporary i nature of Certified Well oritractor Date
By,signing thicm*s form,1 hereby c that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes ?„ ,,,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 informaand alain 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�iW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You May also attach additional pages if necessary.
drilled: /l
SUBMITTAL INSTRUCTIONS
y
9.Total well de 'below land surface: i,`,. J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1f different(example-3 a.200•and 2(3100') construction to the following:"
10.Static water level below topof casing:g: (ft:) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" ' - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) I
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) Method of test: Air Flow 24c.For Water Supple&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 Resources Revised 2-22-2016