GW1--01866_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ITIf1E5.6?^
1.Well Contractor Information:
Robert Teague
.14 WATERIDATES. 14. .'...;1 .?.i$;; ,• a
ar.,....
Well Contractor Name FROM TO DESCRIPTION
2857-A 2 s c,ft zG pft. Z k
�,.5�-ft Li�d rt Z-6
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NC Well Contractor Certification Number
B&K Well Drilling Inc 1$OAR.CASING:(tor-rii»tti;ea'slydw"s RMI1�lER'(8 -Ilibb7eiRt gq,;',
FROM TO
DIAMETER THICKNESS MATERIAL
Company Name 0 ft S? ft 61/8 in. SDR-21 PVC
c]6 INNER:CASING:Okini1§141G'(geut§
2.Well Construction Permit#:a 0 a6 --ill/ 6 ermal she =rAm -t•'
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County, te,Variance,etc.) ft ft. to
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17 SCREEN?_„ . ,_,t. .., ;.: . .e:.. m.v,,I;..
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL `'
°Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) ekesidential Water Supply(single)
ft ft. to
Industrial/Commercial °Residential Water Supply(shared) GROIIi,..
Irrigation 1ff.< :; _ .;;, s : a
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT,
Non-Water Supply Well: ft ft,
Monitoring °Recovery ft. ft.
Injection Well:
Aquifer Recharge ()Groundwater Remediation ft. ft.
Aquifer Storage and Recovery -.19 SAND/GRe VEL PACK.(ifappUirahle} _ M r;,,:,�
()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
Aquifer Test °Stormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft ft-
•
Geothermal(Closed Loop) Tracer - (
° ZOi,DRILLINGLQE attachadditioiiats7teetsif"ce
Geothermal(Heating/Cooling Return) "' ` ` t
$/ $ ( Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,nardn soil/reck type,grain size,etc.)
q O ft.s7 ft6ir ., o �
4.Date Well(s)Completed:7.,' S- 7-+� Well ID# 5�7�ft. 3 > .A��J �/ -
5a.Well Location: a 3 v`� fft't A�r� s
�'+ 0 l( S I�ti�tl10.l\ �1��d a k �r
Facility/Owner Name
Facility ID#(if�plicabl ft ft.
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L! triA ' r �•(NAX.`\l �y.S ‘ U Cl ft. ft. '' 4 � c • 7
Physical Address,City,and Zip ft ft.
r
9,4
--21;RF.hfA72rrC:..:�"r - _ �,�t � iT..�.�r,�.�...z..Y:�t.:4.`.
County Parcel Identification No.(PIN) Ifln. rft'N'' r',•^ ^r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
N W / ✓ -{te a 'I-9
6.Is(are)the well(s)OPernranent or °Temporary Signature of Certified well neffIractor I'm- p 1C e
By signing this form.1 hereby cent fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or 7No with 15A 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 fndlexplain 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:
1 SUBMITTAL INSTRUCTIONS'
9.Total well d th below land surface:- (-f��o (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd( erent(example-3@200'and 2@a 100')
construction to the following:
10.Static water level below top of casing:40
If water level is above casing,use"+ (ft.) Division of Water Resources,Information Processing Unit,
6 /8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 (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 following: j
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection Chlor Tabs 1 1/2 ins the address(es) above, also submit one copy of this form within 30 days of
type: Amount: completion of well construction t I the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources:
Revised 2-22-201 ti
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