GW1--04288_Well Construction - GW1_20240719

Nnt 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 i
ft
ft. ft.
NC Well Cotrtncttx Certification\umber 15.OUTER CA9ING for maltl Wed was OR LINER k
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 IL L(/1 ft 6118 in. SOR-21 PVC
'\ 16.INNER CASING OR TUBING ckosed
2.Well Construction Permit4l _ U FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructs its(i.e.UIC,Cowry,State. Variance,etc.) fL ft in.
3.Well Use(check well use):
fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Mu nicipal/Public fL ft, in.
Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) fc ft ;n•
IndusaiaUCommercial Residential Water Supply(shared) 19.GROUr
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN'T
Non-Water Supply Well: ft. ft
Monitoring 13Rccovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge []Groundwater Remcdiation 19.SAND/GRAVEL PACK e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attack it"ioaai skeeb if
FROM Geothermal Hearin Coolin Return} Other(explain under>*21 Remarks) OM TO DESCRIPTION(color,hard wiLtruck t in shoe etc)
ft. G ft.
4.Date Well(s)Completed,' I — :.Li Well ID# ) ft• j� .0
5a.Well Location: fL
))bt,kc)Lt�S)r trer) f` ft
/
Facility/ am fL ft
c Facility ID#(ifapplicablc) 1 '�' ••� ,.
R
ft. ft.
Physical Addms,City,and Zip � /'01 V!/C/--: ft ft
�J
Z1..REMARKS
County Parcel Identification No.(PIN) t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatin:
N W
6.Is(are)the well(s)OPermanent or Temporary Si AcrC�,,,'ificd Wcll Co trot Dar
By.signing this form.I hereby certift that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or with 15A NCAC 02C.0100 or 15A.NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction informatioplain the nature of the cops of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
g.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
9.Total well depth below land surface: V ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifdifferent(example-3C200 and 2@I00') construction to the following:
10.Static water level below to of casing: 40 p g: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (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: construction to the following:
(i.e.auger,rotary,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 &Injection Welts: In addition to sending the form to
13b.Disinfection type: Chlor Tabs
the address(es) above. also submit one copy of this form within 30 days of
Amount: 1 1t2 tbs 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