GW1--03070_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague
14.WATERZONES
Well Contractor Name F OM TO DESCRIPTION
2857-A 41-L�• z/ 7 6 ft- j� G Jti
NC Well Contractor Certification Number 5-L) ft.,S ft. /j ��.,,,
B& K Well Drilling Inc 15•O�R G(for' `a )t (E, )
�„ ,:
FROM TO DIAMETER THICKNESS MATERIAL
Company Name o ft. 7 L ft• 6 1!8 in' SDR-21 PVC
16.INNER CASIN f)R IT:D NG(¢ea
2.Well Construction Permit#: S FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. C,County,Sm e,Variance,etc) ft ft. in.
3.Well Use(check well use): ft, ft. in. 1
Water Supply Well: 17.SCREEN
` �AgrICUlhlral FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single)
ft ft. in.
Industrial/Commercial °Residential Water Supply(shared) j
Irrigation 18.GROIIT
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 Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology oSubsidence Control ft ft.
Geothermal(Closed Loop) �-yTracer
L! 28.DRILLING LOG(attach a _" £,,4•x, -.v
n
.°Geothermal(Heating/Cooling Return) °Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness sorUrock ripe gram size etc.)
p ft, 714 ft. d J r-1 /l0
4.Date Well(s)Complete?' L"al-) Well ID# 7 il ft. ft. �( �! S C U
5 Well Location: i� - �, + C
1 Gl , \� 1 plc' 140�fl. • ft, h S b s n'itE.acilit�/Owner Name Facility ID#(if applicable) ft. ft.
' - S It )�/e 1 C r r!k ft. ft.Physical Address,,Adddresss,/City,and Zip
ft fL r
i?V 1 ' \C� ' f t�_ i `
S1.REMARKS ��Al� '" x ,rr ,>'
County Parcel Identification No.(PIN) ���Q
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1ri`i A'+-.r:r --,.
(if well field,one lat/long is sufficient) $.04"
22.Certification: 74_.... L7A'C1- 0.3
N -W '/ .3
6.Is(are)the well(s)0Permanent or °Temporary Signahuc ofCertifiied Well Contract ^� &/
Date
..fit Bi.signing ibis form, !herebe certify chat the well(sJ wa (were)constucted in accordance
7.Is this a repair to an existing well: Yes or with ISA NCAC 02C.0/00 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information n lain the nature of the copy of this record has been provided to the well owner.
repair;under#2/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
is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)For multiple wells list all depths ifd different(example-3@2db•and 2@J00) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40 (ft-)
If voter level is above casing,use o •• Division of Water Resources,Information Processing Unit,
it,
'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (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) Method of test: Air Flow 24c. For Water Supply& Injection Wells: In addition to sending the form to
Chloe Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: t t/2 LbS completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016