GW1--01867_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Robert Teague
1.4 wATERZUIVES'taE €, iwat sue! s f _ax.s?i ,t.:r 'd'
Well Contractor Name FROM TO DESCRIPTION _ „,.,, `�..-R.
2857-A o ft. G eft.
NC Well Contractor Certification Number st O sf4 I<- ft. Ar—
Q 4 0
B&K Well Drilling Inc 1is:QUTER AS G.(foil=,nwtl-e sect*elelft)fOlt NEZ(tB� ,7e MA r .1
FROM TO DIAMETER THICKNESS I MATERIAL
Company Name 0 ft• O ft• I 61/8 ' in• SDR-21 If PVC
r ISsINNERiGASING.OR=TOBING"(i ei thermat-closed;F4oji? .I.' t``= _ ,s'�,..= .:.";
2.Well Construction Permit#:QLI v 13 0 1 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.
Water Supply Well: 175SGREEN.. w ,. : s'ysa_
Agricultural FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single)
ft ft. in.
Industrial/Commercial DResidenfial Water Supply(shared)
i$ ROTTT +. „ter y t x_ c< r 4 x;``
Irrigation $r,,,, s_-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge E3Groundwatcr Remediation ft. ft.
Aquifer Storage and Recove 49 SAND/GRAY,ET AcI((ifap`piicable),=4. ', ;r;:g ,t "x?` _
ta
ry DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage ft. ft.
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer
2KDRILL'ING:;LOG:(atfachaddttmnalshe"elsifiia scary). Z,_ ',='"tM s'.:;,;M
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DES'RI (color,h�ness,soiv e,gram size, t.l
oft. 4.Oft. G 6
4.Date Well(s)Completed—L. • Well ID# / 6 ft.9-c c - t_ �e , S 6
Sa.Well Location: Cv rt e/
..A � ��s ft. s ✓/�f l�J�Trrru c. Cry'-- ./ /d-6ySft.Facility/Owner
ne Namem Facility ID#(if applicable) ft. ft _
V Rif ✓1. L )1 C G 1 f'l, n ft. ft. r 6�,,L„l AL." t P' „.;r,,,-)
Physical Address,Ci ,and Zip T ft ft J a �y
,JT,
Cam+.N.\J 1 w2ttiRF1YIARKVag.PWV.M-*v z,:K y.z Pv =r;'�iVPf��YVNM"r z :.g
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G!tvl`.,',1��G":: V(R"
(if well field,one lat/long is sufficient) 22.Certific '
N W
6.Is(are)the well(s) Permanent or Tem ora ign lure of Certified Well C tractor P rYG Date
By signing this form,1 hereby certt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing wells or o 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 constru lion in rmation d e lain the nature of the copy of this record has been provided fo the well owner.
repair under#21 remarks section or on the back of thts 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 details. You may also attach additional pages if necessary.
construction,only 1 G1 is needed. Indicate TOTAL NUMBER of wells
drilled: -.(i
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S (ft.) 24a. For MI Wells: Submit this form within 30 days
For multiple wells list all depths ifdifferent(example-3@2�and 2@100') of completion of well
construction to the following:
10.Static water level below top of casing: 40 (ft.
If water level is above casing,use +' ) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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: i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
/�"� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ..7 (� Method of test: Air Flow 24c.For Water Supply&Iniecti in Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit tine copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2 t bs 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 i
Revised 2-22-2016
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