GW1--01860_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:, . Pol
1.Well Contractor Information: '
Robert Teague 14wnTERzoNEs •:.. : -..7
Well Connector Name FROM TO 4 DESCRIPTION
2857-A 15 a ft. /(v ft. 6 G��,.,
NC Well Contractor Certification Number
Am d ft. u s ft. 1 G
-15:OUTER'CASING.(for u l-cased wetls)OI J NER'{it'a gcable).;;
B&K Well Drilling Inc FROM TO 1DIAMETER THICKNESS MATERIAL
Company Name. 0 ft. IS I ft. ;6'1/8 to SDR-21 PVC
�18 2 .16:-INNER-.CNOOR'CUBING:(gedtltermatcliiiii: loop)'< �...,•.t ':
2.Well Construction Permit#: ' FROM TO ,DIAMETER THICKNESS ' MATERIAL
List all applicable well construction permits(i.e.U1C,County.State.Variance,etc.) ft. ft. ; in.
3.Well Use(check well use): ft. ft. in. .
Water Supply Well: :17.iSEREEh
_FROM TO DIAMETER_ SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
JGeothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. io.
IJIndustrial/Commercial DResidential Water Supply(shared) •:18.OROUT :,,. :, ,: .::.
IlIrrieation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring DRecovery ft. ft.
Injection Well:
[3Aquifer Recharge DGroundwatcr Remediation ft. ft.
a19SANDIGRAVETIPACK'(daptil3cable) ' ,-•. ,. ::; .., ;.. , , :.
DAquifer Storage and Recovery OSalinity Barrier FROM TO 'MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
©Experimental Technology OSubsidence Control ft. • ft.
Geothermal(Closed Loop) OTracer 20.;DRILLING L'f}G(attach addrhanaisheeti if'necessary) :-
DFROM TO DESCRIPTION(icier,hardness,soil/type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#Z 1 Remarks) �ft ,a 1 f(, �A\ •
' r 1 � l,�
4.Date Well(s)Completed:1- D /� { Well ID# � 1 ft. � eft• J (. 6/„.,4
5 Well Location: al) 5f. 1.4 Ws?ft. S jA hour
nz cod ( ft. "l ft. I -�"
Facility/ORiewncdName \� acuity IDm(ifapplicable) ft. ft. '
1 7 \' 1 ON( 1V i S5 c, n 1 L ft. ft. i I. f .-,.,
Physical
l Address,
City,and Z ft. ft. i '' -r`, V `L...
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G01.5A 6 21.itF IARKS' ,A 11411H , , .y rt .•
County Parcel Identification No.(PIN) ;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: a •, 4)
ws ra✓,r;,i;�tj
(if well field,one lat/long is sufficient) 22.Certif[cati I ' l 1
6.Is(are)the weil(s)OPermanent or Temporary Signature of Certified Wet!Con Date
By signing this form.I hereby certify that the w•ell(.r)was(were)consuveted in accordance
7.Is this a repair to an existing well: O Yes or No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information d Main 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well dept elow land surface: % S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths if different(example-3@200'and 2@100) 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 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 Res Iurces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Pi- 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: t 1/2 Lbs completion of well constrs ctii n to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water R1esdurces Revised 2-22-2016