GW1--03080_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD GW_1
For Internal Use Only:
1.Well Contractor Information:
Robert Teague
Well Contractor Name Q
"1WA#
FROM TO _ �,..,v.•„:„ xc y i :s3
2857-A 2 f` DESCRIPTION
F��Z C
NC Well Contractor Certification Number _ y
B& K Well Drilling Inc �"I
<FROM ER CASING.for ,0.,.. ,.. :..Da;:414, s, �".A;:s ; s,,;:.
FROM TO 4.�d...,,,.,T �,a.
[[ DIAMETER THICKNESS MATERIAL
Company Name 0 ft. /� m
61/8 SDR-21 PVC
2.Well Construction Permit#: 16 'CA<SE+1GaR
FROM �^:F' , ... fir- k..:
List all applicable well construction permits(i.e. UIC,Counry,Slate. Variance,etc.) ft TO DIAMETER THICKNESS ``"-`.;.
MATERIAL
ft. in.
3.Well Use(check well use):
k. ft. in.
Water Supply Well: "1?iSE1tF�l,:r,:
AgnCUltural FROM TO 'i' r =�s -x tfir 7. ?Al
E3MuniCipaUPublic DIAMETER SLOT SIZE THICKNESS MATERIAL
Geothermal(Heating/CoolingSupply) ft. ft. rn.
pP Y) Residential Water Supply(single)
Industrial/Commercialft. ft. in.
Residential Water Supply(shared)
Irrigation itGRp133 _
FROM TO -i is METHOD
'"' ...q
Non-Water Supply Well: MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft
Monitoring °Recovery
Injection Well: ft. ft.
Aquifer Recharge °Groundwater Remediation ft. ft
Aquifer Storage and Recovery Salinity Bather ' f aTERIAL
FROM TO MATERIAL 4'='-�.,Aquifer Test DStormwater Drainage ft, ft. EMPLACEMENT METHOD
Experimental Technology E3Subsidence Control ft.
Geothermal(Closed Loop) Tracer ft.
Zo DRILLINGLOG.Ca lt--
Geothermal(Heating/Coolin x
Return FROMKt � •,
g ) Other(explain under#21 Remarks) To �1DESCRIIPTTION(color,barns soil/rock type,grain riuj etc.)
4.Date Well(s)Completed:3-H WellII)# o ft. gO t" V ! r 4- ifee,c r
Sa.Well Location: �.b
177 LR C.lv,4 v a Ion h�.t-cJ S��� !,.
Fac
ility/Owner Name Facility lD#(if applicable)
'� ft.20 o1 d Lbn ) y( ft. ft.
Physical Address,City,and Zip Lv/ !i� ft.
1Lr Jae.. 21.,REMARS.4; d. .
7
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !l` ` •'
.L-:� 'Jr
(if well field,one lat/long is sufficient) fi t4- •I,-
22.Certific
N W
6.Is(are)the well(s)13Permanent or Temporary I
Signature of Certified Well Contra r Date
7.Is this a repair to an existing well: QY¢S or No By signing this form, /hereby certify that the well(s)was(were)constructed in accordance
with ISA If this is a repair,fill out known well construction information lain the nature of the copy fth �ecordAC 2has beenprovided to thOwell own Well Construction Standards and that a
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 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled:
3‘..5— SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths ifdii different(example-30a 200'and 2@100') (ft') 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
If water level is above 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.)
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
(Lc.auger,rotary,cable,direct push,etc.) construction to the following:
I FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
S 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
the address(es) copy days
13b.Disinfection type: Chlor Tabs Amount: 11/2
tbs above, also submit one of this form within 30 of
completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quali
ty ty-Division of Water Resources Revised 2-22-2016