GW1--04233_Well Construction - GW1_20240719

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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 FROM TO DESCRIPTION
ft
2857-A
ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ff a ble
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. ft. 6 118 1 ' I SDR-21 PVC
/� 1 16.INNER CASING OR TUBING eothermal closed-1
2.Well Construction Permit#:LhW�L) -U Q 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable welt construction permits(i.e. UIC,County,State. Variance,etc.) ft. ft. in.
3.Well Use(check well use):
ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) fL ft in.
'Industrial/Commercial Residential Water Supply(shared) 18.GROUT
'Irrigation FROM 1 TO MATERIAL I EMPLACE.MENTMETHOD&.4MOL'NT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft.
Injection Well: ft.
Aquifer Recharge []Groundwater Rcmcdiation D/ ft.
Aquifer Storage and Recovery [)Salinity Barrier FROM
SAND/GRAVEL PACK applicable)
9 g �' � ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheeb if
FROM TO DESCRIPTION(color,hardn 'Urock type, rain sift,etc.)
Geothermal (Heating/Cooling Return) r3Other(explain under#21 Remarks) ft. ft.
1 C
4.Date Well(s)Completed: S- Well ID# ff• , t
5a.Well Location: 6 Z
1�.1,rMctr�1\ �>G�r6�1 f- 5 CtZ3 ft- S 13
Facility/Owner Name .�Fa flay lD#(ifapplicablc) ft. fL -
L C rt. ft.
q �.r-, I � en sty
Physical Address,City,and Zip ft. ft.
1L roc, o)ra a Ci LAN 21.REMARKS
County Parcel Identification No.(PIN) �O�T
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certifica
N W to
6.Is(are)the well(s)oPermanent or Temporary Stgnaturc of Certified Well Con Prior Date
By.signing this form, I hereby c•ernjy that the well(s) was(were)constructed in accordance
7.is this a repair to an existing well: Yes or No with 15A NCK m-C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informat[o nd lain the nature of the copy'of this'record has been provided to the Nell owner.
repair under#21 remarks section or on the back of this fo 23.Site diagram or additional well details:
S.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
ep 9.Total we th below land surface: �0 � (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3C200'and 2@ 100') construction to the following:
10.Static water level below to of casing:40
p g: (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
auger,rotary, construction to the following:
(i.e.au g tary,cable,direct push,etc.)
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&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1i2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Depamnent of Environmental Quality-Division of Water Resources Revised 2-22-2016