GW1--05519_Well Construction - GW1_20240912

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: (/
1.Well Contractor Information: •
Robert Teague Ya:WATERZONEs.,..,..g ,i..g.'l: s:. . ,. ,,. ?ail5:1?3;.
Well Contractor Name FROM TO DESCRIPTION
2857-A i dt 1�2 to ft. 214 O ft.n bel
NC Well Contractor Certification Number ( ft. f'7, I ft.�0 J f� ��
'15CtUTER``C ASING(for multi-cas(ect*elliyOR IANER(if ap`iieuble)
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft.5'' ft. 61/6 1, in. SDR-21 PVC
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/� r CINNERICASING:OR•TUBING.(Aeotherual:closed=oop}..,,.,, ,
2.Well Construction Permit#Sw). - 156.c FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale, ariance,etc.) ft. ft. 1 in.
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3.Well Use(check well use): ft ft to
Water Supply Well: •
47 SCREEN. . ; .;s f. :. r•' a _ :=cs . .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0 Agricultural OMunicipal/Public ft. ft. in.
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OGeothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft ft. in.
E3Industrial/Commercial DResidential Water Supply(shared) :18.GROUT, c., .<
ri Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: ft. ft r,,,, .,a
Monitoring 0 Recovery ft. ft. f"':,`L♦` c:L;
Injection Well:
0Aquifer Recharge [3 GroundwaterRcmcdiation ft ft SEP 1 701A
>19t;SAND/GRAVEL PACK Of applicable) �,. ' ''." = .-r r.
DAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. Irtt:i:r1C+ i r.t7. ;'Jrr r`413`.-�Uri
Aquifer Test �Stormwater Drainage mtc:r..A
0 Experimental Technology 0Subsidence Control ft. ft. a V J
1
DGeothermal(Closed Loop) °Tracer =20:DRILLING I:oG'(atfacliiidditiupalsheets'lf'necessary)';,...4a, ]*; •,.,;
a Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,n�es suiuroc typ gram size,etc.)
( g/ g Other(explain under#21 Remarks) 0 ft. SS ft. \ ) d �
4.Date Well(s)Completed:7",2 -z(1 Well ID# s� ft. a0—�• / � // G�a 2 f c
5a.Well Location: ').,G L (do Sft here ` J &/U.�
J7W M6,11G \�I'' L?b t.SAS - ft- h r�.,,-c) /--e_
Facility/Owner Name Facility ID#(ifa licablc) ft. ft.
i1 d ft. ft.
Physical dd�dresss,�City,and Zip
ft. ft. •
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1>/�..(/U-./�) \ 21.REMARK9c ... . _ . a r.
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific I .
N W 7•-7 2-1
6.Is(are)the well(s)JPermanent or 0Temporary tgnature o ertificd ell C ractor Date f
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By signing this form,I hereby certify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
5 If this is a repair,fill out known well construction informati an plain the nature of the copy of this record has been provided,''to the well owner.
7 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
i 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: �6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: i'
10.Static water level 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.) 24b. For Injection 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) 3 V Method of test: Air Flow ' 24c.For Water Supply&lniection Wells: In addition to sending the foim to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1t2Lbs completion of well construction i ti the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcci Revised 2-22-2016