GW1--04283_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 WNES
FROM TO DESCRIPTIONS
Well Contractor Name � ft
2857-A
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-awed walls OR LIN "ble
B & K Well Drilling Inc FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 ft —J ft 61/8 in' I SOR-21 PVC
16.INNER CAS114P.OR TUBING thermal
2.Well Construction Permit#::WC2-C ��o� U FROM TO DIAMETER 7HICKNESS MATERIAL
List all applicable well construction permits(i-e.UIC,County,State. Variance,err.)
ft. ft, in.
3.Well Use(check well use):
fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
Industrial/Commercial E3Resideritial Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring 13Recovery ft. ft.
Injection Well:
Aquifer Recharge [3Groundwatcr Rcmcdiation fa ft
Aquifer Storage and Recovery Salinity Barrier 1F92OM TO L PACK MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormw•ater Drainage ft ft
Experimental Technology OSubsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.DRMLLNG LOG attecit addltioaai sheets if
Geothermal Hearin Coolln Return) Other(explain under#21 Remarks) FROM TO DESCRIPTIOr•(color,hardness,soiltrock a rain sbz.etc.)
L ft ft
4.Date Well(s)Completed`r 2 ` Well ID# '74
ft•
5a.Well Location: Ct rt
a •2-b O h ft ft.
'y r r`
aeility/Owner Name Facility ID#(if applicable) ft ft �
^t ft ft. 46.. V 11—
Physical Address,City,and Zip f V ft. ft JUL 1 5 2024
n 21.REMARKS
County t Parcel Identification No.(PIN) 9D k A y
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 13Temporary gw c ofCcrtified Well Conaco# Datc
By signing this form,l hereby cerlify that the vvell(s) was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or Yo with 15A NCAC 01C.0100 or ISA NCAC 01C.0100 well Construction Standards and that a
If this is a repair,fill out known well construction information nd,.`plain the nature o/'1he copy of this record has heen 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 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- is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
F 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 ifdii ferent(example-3@100'and 2V 100') construction to the following:
10.Static water level below top of casing:40 Division of Water Resources,Information Processing Unit,
lfwater level is ahove casing,use"+" 1617 Mail Service Center,Raleigh,NC 276"A 617
11.Borehole diameter: 6 1/8 (in.) 246.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 276"-1636
13a.Yield(gpm) V Method of test: Air Flow 24c-For Water Suooly&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1tz tbs 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Rcviscd 2-22-2016