GW1--04270_Well Construction - GW1_20240719

Print Form
. . .. .....:.:.:...:
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2857-A
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ble
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fL ft. 61/8 1O' SDR-21 PVC
' 16.INNER CASING OR TUBING(geothermal closed-1
2.Well Construction Permit#: 03e FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well 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 ©Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge []Groundwater Rcmediation
19.SAND/GRAVEL PACK a ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage ft. ft•
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILL LOG attach additional sheets if
Geothermal Heatin Coohn Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness.wil/rock tvpc grain size,etc)
4.Date Well(s)Completed: Well 1D# ft 2pls�ft
5a.Well Location: 3ct!�fL
W i s o n
Facili�ty/OwncrName Facility lD#(ifapplicablc) ft. ft-
/ --• -, _
,,6z��Z _ ;;;4A ft.
ft.
Physical Address,City,and Zip ft. ft
L, nod 1 10 0 6 p�4, 4 21.REMARKS
County Parcel Identification No.(PIN) Ifhi:i,;K A r - +J**
df�Lt 1-A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)oPermanent or E3Temporary S gnaturc of Cenificd Well Con or Date
�dlczin
By.signing this form, /herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or with 114 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction informali the nature of the copy of this record has been provided to the Kell owner.
repair under#21 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 I 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 dept 1 below land surface: e� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3[7a 200'and 2C100') construction to the following:
10.Statle water level below top of casing: 40 Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b. For Iniection 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,direcK 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) t Method of test: Air Flow 24c. For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of weal construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of W'atcr Resources Revised 2-22-2016