GW1--05485_Well Construction - GW1_20240912

WELL CONSTRUCTION RECORD(GW-1) # ° �°
For Internal Use Only: . .,
1.Well Contractor Information:
Robert Teague
T4FVATER'ZONES _
Well Contractor Name
FROM TO DESCRIPTION
2857-A Gjs ft. z b 0 ft ci
NC Well Contractor Certification Number
z.zrt SOft. 2j jp1,t.
B&K Well Drilling Inc 1$`to R:CCASINGG(foYmoltkailrrliefliyOltiLINE t_.lieadle
FROM I✓ % .T
DIAMETER THICKNESS MATERIAL
Company Name 0 61/8' to SDR-21 PVC
L1e'S� S b 611M1�R.t l4)> MEETeot telE SS
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL f
List all applicable well construction permits(i.e.UIC,County,State,Variance,' etc.) ft ft. in.
3.Well Use(check well use): ft. ft. • in.
Water Supply Well: 17 iSCREF,N'
()Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
()Municipal/Public ft. ft. in.
()Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single)
ft ft. in.
()Industrial/Commercial
()Residential Water Supply(shared)
( Irrigation 18:(GROb1`.i:.'i , , : . _.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring ()Recovery
Injection Well: ft. ft.
()Aquifer Recharge ()Groundwater Rcmediation ft ft
()Aquifer Storage and Recoveryv 191 SAND/GRA"STEL PA'CK(it:appfcsble) +w
()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
()Aquifer Test 0Stormwater Drainage ft. ft.
()Experimental Technology ()Subsidence Control ft. ft.
()Geothermal(Closed Loop) Tracer
() ;3o bRILE.IN LOG(attiell ddthaaal sheelslt eccasaryj l ;; .:.g
()Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardn soil/rock type Rrsin svx etc.)
Oft .S " _ i 4.Date Well(s) d �
Complete `t S 4 Well ID# SG// d ft i- •- ''
Sa �b
Well Location: •
ft b g c ^ . � � ��/
ft.
Facility/Owner Name-Ti vhic4k ( Facility ID#(if applicable) fL ft.
D.5 3 / -I r 9e.par-7 fh� St rt. ft. LL r.,:> S .,,, i
Physical Address,City,and Zip ft ft
C 21 REIVIARIcs r`t-(� q ry�
County Parcel Identification No.(PIN) ,,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Dili Cu 3Lrisr
(if well field,one 1at/long is sufficient)
22.Certi�'/fic 't: � -N W ✓ 1 c
_
6.Is(are)the well(s)01Permanent or ()(Temporary
Si c of Certified Well Contractor 1 Date
ning this form,I hereby
in accord
7.Is this a repair to an existing well: ()Yes or ()No witht15A NCAC 02C.0100 or 1SAtify NCAC 02C.0200that the well(1Well Co structucted ionw (were) t Standards and haatca
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.
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 14GW-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:
For multiple wells list all depths if different(example-3@200'and 2@100') (ft') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40
If water level is above casing,use"+ (ft.) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) i
24b.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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 112 Lbs 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
Revised 2-22-2016