GW1--03118_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD GW_1
For Internal Use Only: ¢' '
1.Well Contractor Information:
Robert Teague
Well Contractor Name 1t:Wtt111tZpia:'
FROM TO * �. ..,k P.. .,. ;,
DESCRIPTION
2857-A /'I"
NC Well Contractor Certification Number fL ft.
B & K Well Drilling Inc atlaEI:cxslxc m a _
FROM TO DIAMETER THICKNESSIr.
Company Name c ft. /f ft. MATERIAL
61/8 1p SDR-21 PVC
1t 2.Well Construction Permit#: ^ i•
FROM List all applicable well construction permits(i.e. UIC,Coun TO DIAMETER A a :,
ry.State.Variance,etc.) fr. THICKNESS MATE L RIAL
ft. in.
3.Well Use(check well use):
ft. ft. in. —I
Water Supply Well: i7:SCREiyilt70
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
; Agricultural 0Municipal/Public
a Geothermal(Heating/Cooling Supply) ft. ft.
�R�'idential Water Supply(single) Inil
_—
lndustriaUConunercial ft ft.
Residential Water Supply(shared)
Irritation is.GRt?IFI>:
Non-Water Supply Well: FROM TO MATERIAL .:. :n ,"
EMPLACEMENT METHOD&AMOUNT
ft, ft.
Monitoring °Recovery
Injection Well: ft. ft.al —Aquifer RechargeGroundwatcr Remediation ft it. —
1Aquifer Storage and Recovery °Salinity Barrier ' " R CIf
Aquifer Test FROM TO -
�Stormwater Drainage ft. ft EMPLACEMENT METHOD
ir Experimental Technology °Subsidence Control ft. j
Geothermal(Closed Loop) °Tracer ft.
20‘,DRILUNGLOW at[scli asf:§ sR _<"
a Geothermal(Heatin•Coolin• Return) FROM,'Other(explain under#21 Remarks) TO DESCRIPTION(color,hardness, _ e,etc.rt fress,soil/rock �.e,:rain size,
4.Date Well(s)Completed: 3 a=_a Li�yell l V ikall
= J
5a.Well Location: MillIMAIL��
l a, �r i 11 t lnrl 'NM fL - _
Facility/Owner Name Facility ID#(if applicable) ft. ft
_ 13icvcr si aYf L1 � a ft. ft. '...`
Physical Address,C. , d Zip "f 1•-•a,
ft, ft.
� i1 MAY 2
r
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certifica'on:
N W
6.Is(are)the well(s)Opermanent or Tem ra Si a J a L po��ry// Signature of Certified Well Co ctor Date
)constructed in accordance
7.Is this a repair to an existing well: Q yes or By signing this form, !hereby cerr 'that the well(s)was
with 10 t NC/IC 02C or vi NCAC 02C.0200 Well Construction Standards and that a
If thi is a repair,fall out known wellr can the ks informationhio nd lain 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.
or
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Site du a the back of this page a eltoetails:
provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells You maya g
drilled: construction details. You may also attach additional pages if necessary.
9.Total well epth below land surface: 3 6..:_c SUBMITTAL INSTRUCTIONS
For multiple wells list all depths if different(example-3@200'and MO 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below topof casing: 40 construction to the following:
If water level is above casing,use (ft.)
Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1�8 1617 Mail Service Center,Raleigh,NC 27699-1617
(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.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) Method of test: Air Flow
24c.For Water Supply&Iniec6on Wells: In addition to sending the form to
Chloe Tabs
13b.Disinfection type: t t/2 ws the address(es) above, also submit one copy Amount: completion of well construction to the county healtrhsdepartment form lof thn 30days
county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016