GW1--04232_Well Construction - GW1_20240719

I POntform
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2857-A pftG1r�
I ft. ft
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(ft bit)
B & K Well Drilling Inc FROM I TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft V.2-7 6 118 in' SDR-21 PVC
i 16.INNER CAS1NTUBING(geothermal elaed-loop)
2.Well Construction Permit#: I FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State. Variance.etc.) ft 1 n. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: . - 17.SCREEN
FROM TO 1 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single) ft ft in.
Industrial/Commercial OResidential Water Supply(shared) ls.GROITT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft. I
Injection Well:
ft. ft.
Aquifer Recharge DGroundwatcr Rcmcdiation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional shah if necessary)
Geothermal(Heating/Cooling Return) Other(explain under t21 Remarks) FROM TO DESCRIPTION(color.hardness u/rock type grain sine etc.)
E') ft. 1 ZZn6 ' ( ' cs, , `c, t
4.Date Well(s)Completed: S- A Z'.)-L\Well ID# 1 )- 7 ')-, Sift...1,1C,r.) A _) /di/ <_ 1
5a.Well Loc don: ft. ft
Faci7lity/OwnerN(aamme l Facility ID#(if appli)ca lc)j ft. ft. E^Ns r.-o, i /j c
51 Inn i { be r`�` cku rci1 ) ! ft. ft.
Physical Address,City,and Zip 1 ft. ft JUL 1 y 1014
CrAA Ir) 1 1 111 1 21.REMARKS
1 krifr-4164'tat +
County Parcel Identification No.(PIN) DoA °1K
II
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certificadon:�
WN
S_ )-a - .2Lj
6.Is(are)the well(s)13Permanent or OTemporary Signature of Certified Well C clot Date
By signing this form,I hereby certify that the wells) was(were)constructed in accordance
7.is this a repair to an existing well: Yes or No with 15A.VCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information d plain the nature(If 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-i 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: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(eramp/e- C200'and 2 100')
construction to the following:
10.Static water level below top of casing: 40
(ft) Division of Water Resources,Information Processing Unit,
If water level is shove casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (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) 2 O Method of test: Air Flow 24c. For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs u2 Lbs 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