GW1--01872_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-I) i 6^ itFOf i
For Internal Use Only: i
1.Well Contractor Information:
Robert Teague
:14;vwATERZons .:::`
( Well Contractor Name R IP �`;
FROM TO DESCRIPTION �� 4."
2857-A 2-C-3 t 2.75 it. �l L��
NC Well Contractor Certification Number ft ft
B&K Well Drilling Inc is OUTEItC SINNG:(ftifmuItkiiiitWeILWORL1NER4fii -rz blej g :_:;.,,
FROM TO DIAMETER THICKNESS J MATERIAL
Company Name 0 ft' ,d`✓'t- 6 1/8 , rn• SDR-21 PVC
ld iINNERICASING(3R'fUSTNG(k%eotheruial dosed-lppji) ,M
2.Well Construction Permit#: FROM TO
List all applicable well construction permits(i.e.UIC,Coto ty,State.Variance,etc.) ft. ft. DIAMETER in. THICKNESS MATERIAL
3.Well Use(check well use): ft. ft. 1 in. •
Water Supply Well: 17:$GREEN .
Agricultural • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL DMunicipal/Public ft. ft. • in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
ft ft. in.
Industrial/Commercial
Residential Water Supply(shared)
1V6R0133 .;:
Irrigation « a<., '_
FROM TO tMATERIAL "EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery •
Injection Well: _ ft. ft.
Aquifer Recharge OGroundwatcr Remediation ft. ft
Aquifer Storage and Recovery Salinity Barrier '19.tSAND/GRAVELPACK(ifapplicable) _, , , \,,mt `i
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer Zo DR1LL-ING LOG(atfaeliaritEtiii iilsfie dilff:ce
FROM TO DESCRIPTION(color,bard soiUrock �.m
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) type,grain size,etc.)
d ft. .i fi. \,r4, ,s
4.Date Well(s)Completed:I-1.�,- 2-9 Well ID# / eft, i G . ,4 c'r J L --�
5a.Well Location: C�.ra 1, y� 5 ;i k IY— Cat
1
r [
1;1' (y c,2, ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. r :u""'j) A.'rl
•
L� ft.. ft, z s.,...,tam
Ph sical Address,City,and Zip ft. ft MAN 2 G 20z
r 1 pit�/ Z1:32E14FARICS =' ( t
V County Parcel Identification No.(PIN) GVIO ,,. a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certif don:
N W a.- (9
6.Is(are)the well(s)OPermanent or EITemporary i attire of Certified Well Cp acior`"� Date
By.signing this form,I hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 15A NCAC 02C.0100 or 1SA NC4C 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well constru ion'formation and explain 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 '
9.Total well depth elow land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list 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"+"
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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: Air Flow 24c. For Water Supply&Iniection Wells: In addition to sending the form to
e• Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
1 1/2 u's 13b.Disinfection type: Amount: 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