GW1--04290_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
FROM TO UtSCRIPTION
Well Contractor Name
FL ft. �
2857-A
ft. ft
NC Well Contractor Certification Number 15,OUTER CASLNG for multi-wed wdbj OR LIIMEX ble
B & K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft ft 81/8 in' SDR-21 PVC
Company Name 16Ii�0ERCASINGORTUBING thermal
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
Use all applicable well construction permits(i.e.UIC,County.State. Variance,e(c.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public fL ft. io-
Geothermal(HeatinglCooling Supply) OResidential Water Supply(single) fL ft
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.4.MOL'NT
Non-Water Supply Well: ft ft
Monitoring 13 Recovery gJN
ft.Injection Well: ft.Aquifer Recharge 13Groundwatcr RcmcdiationRAVEL PACK a bleAquifer Storage and Recovery Salinity Barrier TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainageft.Experimental Technology Subsidence Control ftGeothermal(Closed Loop) Tracer G t OG attach additwe:i sheets KGeothermal Heatin Coolie Return) Other(ex lain under f21 Remarks) To D RIPTION(cobr, raoen soiV k e la afa«e)
[" ft.4.Date Wells)Completz-- Weil ID# ft5a-Well Location. Lft. �-►.
ttF�acility/Owncr Name cili1ty[Dt?(ifapplica�blc) / ft. f6 »
,S�Cc�aL" ' `1 CI e tl—�sel t r ft. ft. 1
v ft.Physical Atidress,City,and Zip ft.
21.REMARKS n
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one]at/long is sufficient) 22.Certification: /
N W
C /
6.Is(are)the well(s)oPermanent or E37remporary Signature of Certified Wcll Contrac r Datc
By signing this farm, l hereby cert�that the%vell(s)was(were)coratucied in accordance
7.Is this a repair to an existing well: []Yes or o with 15d NC.AC 03C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
jthis is a repair,fill out known well construction information a splain the nature oJ'ihe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofrhis 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 1 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 below land surfacer t� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(arample-3C200'and 2@ 100') construction to the following:
10.Static water level below top of casing:40 Division of Water Resources,Information Processing Unit,
Tw•ater level is above easing,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: construction
Rotary above, also submit one copy of this form within 30 days of completion of well
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 Sunniv& Injection Wells: In addition to sending the form to
Chloe Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1/2I�s 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 Revised2-22-2016