GW1--04289_Well Construction - GW1_20240719

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 1 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2857-A
f fL , fL jy�
NC Well Contractor Certification Number 15.OUTER CAS LYG for In eas OR LINER ble
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name0 fL �1 fL 6 VB in- SDR-21 PVC
16.INNER CASINGORTURING 60VAtdosed
2.Well Construction Permit#: FROM I TO L DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State. Variance.etc.) fL ft. in.
3.Well Use(check well use): fL ft. in.
IN
ater•Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESSMATERIAL
Agricultural E)Municipal/Pubiic ft. ft. in.
Geothermal(ReatingiCooiing Supply) Residential Water Supply(single) fL ft.Industrial/Commercial Residential Water Supply(shared) ROUTETIrrl ation FROM TO MATERIAL EMPLACEMENT MHOD&.4.MOCNT
on-Water Supply Well: ft.Monitoring Recovery ft. ft.
jection Well: fL fLAquifer Recharge 13Groundwatcr Remediation19.SAND/GRAVEL PACK a bleAquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODAquifer Test 13 Stormwater Drainage ft.Experimental Technology Subsidence Control it.Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additionslreeb If Geothermal Hearin Coolin Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color.hardnea soiilrosk a tarn sirs.eto)
ft. ft
4.Date Well(s)Complettil:!.ST Well ID# ft. ft.
5a.Well Location: f4.
Lt-Na �S ti S' ward, fL ft.
Facility/Owner mc Facility ID#(if applicable) ft, fL `
Physical Address,City, d Zip C.6 V A—tr fv ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certific
N W
6.Is(are)the weli(s)oPermanent or Temporary Sienature of Certified Wcll Con ctor Date
Od
tic signing Thisform,I hereby certify that the wellfs) was(were)constructed in accordance
7.Is this a repair to an existing well• OYes or �iih 15A,VCACO2C.0100or15ANCACO2C.0200 Well Construction Standards and that a
ifthis it a repair,fill out known well construction information lain the nature e0he copy of this record has been provided to the well oKner.
repair under#21 remarks section or on the back of this form.
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 weli site details or well
construction,only I 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 t w land surfacer (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3@200'and 2`100� construction to the following:
10.Static 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: 6 118 (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
12 construction to the following:
.au
ger,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&lniection Wells: In addition to sending the form to
Chlor Tabs >1/2 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 Watcr Resources Revised 2-22-2016