GW1--03072_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD GW-1 F 1- s. Form
For Internal Use Only:
1.Well Contractor Information:
Robert Teague
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION'
2857-A ft. ft.
NC Well Contractor Certification Number ft. ft.
B& K Well Drilling Inc 15.OUTER CASLNG(for multi-cased wells)OR LINER(X ' 1
FROM t TOI , DIAMETER THICKNESS MATERIAL
Company Name o ft. 1 J( ft- 6 1/8 in• SDR-21 PVC
' 16.INNER CASING OR TUBING(geothermal cloa.loe 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC �.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: . 17.SCREEN -
QAgriCUl[ural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
()Municipal/Public fL ft. in.
()Geothermal(Heating/Cooling Supply) EDResidential Water Supply(single)
ft ft. in.
Industrial/Commercial Residential Water Supply(shared)
Irrigation 18.GROUT
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
()Monitoring ()Recovery
Injection Well: ft. ft.
()Aquifer Recharge ()Groundwater Remediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK Of applicable) '. .
FROM TO MATERIAL II EMPLACEMENT METHOD Aquifer Test ()Stotmwater Drainage ft. ft. f
()Experimental Technology ()Subsidence Control ft. ft
()Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attactradditiemd sleets if tae may):: .
Geothermal(Heating/Coo/ling Return) Other(explain under#21 Remarks) FROM TO]� �D�ESCRIPTION((ccoolor,hhaa ,ssoit'rock type,grain size,Mp)
4.Date Wel(s)Completed-�J Well ID# v ft• .`" ii n ) " " J`�•
5a.Well Location: G 3S S6-N
C 3 ��
�rrJ6 n Col ley ft t
Faacility/OwnerrNamme F cif ID#(ifapplicable) fL ft.
k r1.1I� ft. ft
� .
` , J 0c, i1._.a
+,�
Physical Address,City,and Zip �6-4 /�+ ft- , ft- I �i'IA Y 2 :e, 2024
13 1)i-1/ 21.REMARKS:
County
Parcel Identification No.(PIN) ' };
�Y�:6•+-L,tJ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N W `
6.Is(are)the well(s)43Permanent or ()Temporary Signature of Certified well✓Con or Date `�`��
..��jj Si signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or No 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 a'n' plain 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 I 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 bell land surface: Ss (fL)
For multiple wells list all depths ifdifferent(example-3@20 and 2@!00') 24a. For MI Wells: Submit this form within 30 days of completion of well
construction to the following:
40
10.Static water level below top of casing:
If water level is above casing,use"+ MODivision of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Infection 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.c.auger,rotary,cable,direct push,etc.) construction Co the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) S Method of test: Air Flow 24c. For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:Chloe Tabs 1 1/2 ins 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