GW1--05477_Well Construction - GW1_20240912

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1
Robert Teague -14.WATERZONEs:• i i• . .
Well Contractor Name FROM TO DESCRIPTION
2857-A . '2.t:5 ft• 2SS ft' ,ID p 171
NC Well Contractor Certification Number (viz ft j+)$ ft f I?
15.OUTER CASlNG.(for mold-cased )OR'LINER(if' cable) . .
B& K Well Drilling Inc FROM TO DIAMET R THICKNESSMATERIAL
Company Name 0 f 1; ft 61/8 rn• SDR-21 PVC
• /1 r y y.� ].6AINNER CASING OR TUBING(gedthermal:cloaed-loop}" :=
2.Well Construction Permit#: JU q-q FROM TO I DIAMETER THICKNESS MATERIAL
•
List all applicable well construction permits(i.e.NC,County.State.Variance,etc.) ft ft in.
3.Well Use(check well use):
ft ft. in.
Water Supply Well: 17.SCREEN •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
. I3Agricultural OMunicipal/PUblic ft ft. in.
Geothermal(Heating/Cooling Supply) IRResidential Water Supply(single)' tt• ft in,
Industrial/Commercial DResidential Water Supply 1 (shared) ".18 --
:.CROIIT,
flIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - D ft Zo ft• 0.4ok.fc
0Monitoring EtRecovery ft. ft.
Injection Well:
DAquifcr Recharge . .DGroundwatcr Rcmcdiation fr. it
Aquifer Storage and Recovery OSalini Barrier 'SAND/GRAVELOPACK(MATERIAL • '
tY FROM TO MATERIAL EMPLACEMENT METHOD
10Aquifer Test 0Stormwater Drainage ft. ft. -
DExperimental Technology 0Subsidence Control . ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary).::` w,,.. <r'�::::;
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(cola hardness soiUroek typeiarain,size..tc.)•►e
(r4.$1
4.Date Well(s)Completed:'0��3 Z7 Well ID# IWO* S ft ft ' �wc U C P 1 2 21 24
5a.W U Location: 7.Ds ft. Liu ft. tt. ( 4 y'Iite Ir.ro:'T-.Fi{;rn y,,.,._.,_
�l�l
rhL 11 405 ft to^6 ft• /q re -1•- so-Cipa.rc., °''N c U
� ^A �'
Facility/Owner c Facility ID#(if applicable) fYYn It..)‘ft Q V‘ ft `� .S It �i lRQ
6tf�l (/�r^ n�a11�RCA � i� Ct '77Qj'} ft. iJ ft ���777 i ,
Physical Address,City,and Zip ft. ft. '
413,,,.e .w7061 •21iREMARI S•
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lst/long is sufficient)
22.�etti aria
N W J`/J • P
3_/____q_
6.IS(are)the well(s) Permanent or Temporary Signature of Ccnificd ell Con for 11' Dat•
By signing this form,i hereby certh that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or ISA:VCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. ' 1
' 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 GT 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: AO (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi('erent(example-3@a 200'and 2@100') construction to the following: 1 '
10.Static water ievel below top of casing:40 (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 1/8 (in.)
246,For injection 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:
I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, •
[ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also dubmit one copy of this form within 30 days of
Chlor Tabs 1 1/2 Lbs
13b completion of well constructil n+to the county health department of the county
where constructed.
1 '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rcsourccs Revised 2-22-2016