GW1--01868_Well Construction - GW1_20240322

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I bail~-WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,—,
1.Well Contractor Information: •
Robert Teague
14 WATEK'Zo rl . a ,�,
Well Contractor Name FROM TO DESCRIPTION k
2857-A .3-5 ef•• gc of 1 I' ip
NC Well Contractor Certification Number P 6 aft $'l/5 ft. f 1 f L pi,
&K Well Drilling Inc 'FROM ed OW (;r .-. i lgi, _'
FROM I T'O DIAMETER THICKNESS MATERIAL
Company Name 0 ft I/ ft
!'� 6 118 tn• SDR-21 PVC
fit' ? a b� /� l4 INNER`easll�GOR r€€ AMETeothe elICKNESS _,- ,•
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.
Water Supply Well: 17:SCREEN w s'• *,
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft, •in.
Geothermal(Heating/Cooling Supply) pnResidential Water Supply(single)
Industrial/Commercialft ft m
Residential Water Supply(shared)
Irrigation 1t1 GROI ,,, -:• :. 1 ;f
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • ft. ft
Monitoring E3Recovery
Injection Well: ft. ft.
Aquifer Recharge E3Groundwatcr Remediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19 SAND/GRAVEL-PACKs(if applicable) x
`
FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test DStormwater Drainage ft: ft.
Experimental Technology E3Subsidence Control
ft. ft.
Geothermal(Closed Loop) OTracer
•
20.rDR11'LINGLOG;(attieli dttioiislslicefsifaecessarY)<
Geothermal(Heating/Cooling RetumFROM TO DESCRIPTION(color.harsh Iurork ,
( g ) �IOther(explain under#21 Remarks) le ft. -6i �tyyppe,grain size,ete.)
•
4.Date Well(s)Completed: -a Well ID# t. Cft. +,I�� 1� r o�•" '
„2 6—,es. lelcur f
5a.Well Location: ') t ';b ft. gc.44/1
e'
rCU\J I-"Q NC- ._ k b • ft. 1'`�
FacilitylOwnerName ���_ �wr�� ��
Facility 1D#(if applicable) !67 t Gam- t '1 C
r_ / ft. ( v ft.Ilan)
rV J /��_
Physical Address,City,and Zip f ft. I ft.
•
2idRE1tL41iICSr=` -.;vi � ,n•!i�"� 1�•T ('t�yry:as
County ^'+..Y. ry y� ;1 a
Parcel Identification No.(PIN) i . iiiuxa99II
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I MAW 2
Z 2024
(if well field,one lat/long is sufficient)
22.Certificati Inf
rt
N �j t.t :C1 .91:y.�c Ot �ty
w ,t DWO? 1`-
did/
6.Is(are)the wells) Permanent or Temporary Signature of Certified Well Con tor
+ Date
By signing this form,1 hereby certify that the well(s)war(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
this is a repair,fill out known well construction information pi,,,,,lain the nature of the copy of this record has been provided to the well owner.
If
repair under#21 remarks section or on the back of this form. i
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also;attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well dept below land surface:
For multiple wells list all depths ifdi erenr(example-3ea20 'and 100') (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40
•limiter level is shove casing,use'+ (ft) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 1 1
24b.For Infection Wells: In addition to sending the form to the address in 74a
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) `.„c Method of test: Air Flow 24c. For Water Supply&Infection Wells: In addition to sending the form to
Chl Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:or 1 112 Lb or 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