GW1--03081_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Robert Teague ' 14.WATER ZONES
Well Contractor Name PROM TO DESCRIPTION
2857-A
1/5 "ft. f CO ft. ./r ,(P s—
et.) ft G _
NC Well Contractor Certification Number 13.OUTER CASING(for multi-cased! ells) R LINER(ff ble)
B & K Well Drilling Inc FROM /T.O DIAMETER THICKNESS MATERIAL
Company Name 0 ft. G� ft. 6 1/8 1O' SDR-21 PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: / l,I 2 S FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U/C.�'ounty.State. Variance,etc.) ft. ft. in.
3.Well Use(check well use):
ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
13Agricultural 0 M unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) fL ft. in,
OIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
IlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
13 Mon itoring 0Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge DGroundwater Remcdiation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EiSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C]Stormwater Drainage ft. ft.
Experimental Technology EiSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardn soil/rock type grain size.etc.)
./' 6 ft. if 0 ft. d ; irk >
4 Date Well(s)Completeti�'1 4� L`7 Well Gt 6 ft•;G3ft• )_ref J e�/��
.Well Location: `j � L 34 /Al`6./d f'S�(>T "f / G e-----
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1•-; , .i '• f�-•-7-)Li ?b
•�t...t i/ .j
S- ,-I 5 Cr -c_e_1r\ Pr ft. ft. A,
Physical Address,City,and Zip ft. ft. MA r 2 2024
21.REMARKS
U r i i,.::..:.. :', ,-
• • .:_.11 et
County Parcel Identification No.(PIN) W;(,'3t►J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N W • / `1 0, 3 _�7
6.is(are)the well(s)#Permanent or ()Temporary • at of crtificd Well Contractor Date
By signing this form, /hereby certify that the well(s) was(were)constructed in accordance
7.is this a repair to an existing well: QYes or o with I5A.VC.AC 02C.0100 or 15A.NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction inform ton an 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-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 below land surface: 3 6 5 (ft) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i different(exam le-3@200'an p
n p lr C/��') construction to the following:
10.Static water level below topof casing:40 \
(ft.) Division of Water Resources,information Processing Unit, J
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 S Method of test: Air Flow 24c.For Water Supply& Injection Wells: In addition to sending the form to
Chlor Tabs tiz tbs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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