GW1--04230_Well Construction - GW1_20240719

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 1 14.WATER ZONES
Well Contractor Name
FROM i TO DESCRIPTION
2857-A {2-14 lft- :-S-G . .-1 I tIP yti
NC Well Contractor Certification Number 1+06. Lit
15.OUTER CNG(for multi-eased wells)OR LINER(if ble)
B & K Well Drilling Inc . FROM TO-� DIAMETER THICKNESS MATERIAL
Company Name 0 fL (.; A,ft g ttg in. SDR-21 PVC
�� O 16.INNER CASING OR TUBING(geotbermai closed-kW2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State. Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: . - 17.SCREEN
DA Cllltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft ft. in.
(3industrial/Commercial OResidential Water Supply(shared)
18.GROUT
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNI
Non-Water Supply Well: ft, ft•
C)Monitoring (3 Recovery ft. ft.
injection Well:
Aquifer Recharge ft. ft.
90Groundwater Rcmcdiation
Aquifer Storage and Recovery SalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test OStormwater Drainage ft. ft.
OExperimental Technology Subsidence Control ft. ft.
OGeothetmal(Closed Loop) 0 Tracer 20.DRILLING LOG(attack additional sheets if necessary)
Geothermal(Heating/Cooling Return) l )Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hairdo soil/rock type,grain sae.etc.)
ft-
4.Date Well(s)Completed4 �`���'`I Well 1D# I � ft• L� �n �t X'� � p�'
S • fit• hckrd alL.<- )--c: ' c
5a.Well Location: 'a V - 0_ .fL ) ��,� ,S �e
O {-\L-L-IZ 1�\1 0 A(-,A o p'�.t,r `2 a - lst- har-(cS
Facility/Owner Name Facility ID#(if applicable) 1 ft. L
S$IIN H‘ erh C b Y Q,S� -I . ft. ft.
Physical Address,City,and Zip 1-"'d $ ft. ft. I' �./E 1.)
`_'fi. n)' . _
L% `-\L -,0\Y1It O'‘C\ 21.REMARKS JUL
County Parcel Identification No.(PIN) I J U L 1 9 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 19 ,
(if well field,one lat/long is sufficient) IfrC.:P?ed` ' a•� . J�
22.Certification: DrK.Ca S,{�,y
N W �, ......r 1G _?4
6.Is(are)the wells)jaPermanent or DTemporary Signature of Certified Well Con r Date
By signing this form, I hereby certif}'that the well(s)was(were)constructed in accordanc
7.Is this a repair to an existing well: D Yes or*Ilio rirh/S f;VC.4C 02C.0100 or ISA CAC 02C.0200 Well Construction Standards and that
If this is a repair.fill out known well construction informationain the nature 4 the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobeiDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or wel
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 de low land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of wel
For multiple wells list all depths if different(example-3@200'and 2@100')
construction to the following:
10.Static water level below top of casing:40
(ft-
If
water level is above casing,use o " ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b. For lniection Wells: in addition to sending the form to the address in 24;
12.Well construction method: Air Rotary above, also submit one copy of this form within 30 days of completion of wel
(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) ... ...no Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form tc
Chloe Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 1/2 Lbs completion of well construction to the county health department of the count)
where constructed.
Form GW-I North Carolina Department of Environmental Revised 2-22-201t
Quality-Division of Water Resources