GW1--06601_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: .
1.Well Contractor Information: I
Robert Teague 14:WATER'ZONES I . •• •
•
Well Contractor Name FROM TA UESGRI�t'ION
2857-A .1(0-ID' 1 ft. 1. !Liap M .
NC Well Contractor Certification Number 5J O ft. s ft , r/ h
15.OUTER CASING{for multi-ca5 wells)OR'LINER(if applicable)
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS } MATERIAL
o fL 6 ft 6 1i8 in' SDR-21 PVC •
Company Name
• ����1 -•16.INNER CASING ORTUBING(geothermal closed400p) .. .
2.Well Construction Permit# 7 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.Comity,State.Variance.etc.) fL ft 1 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 ft. ft. in.
OGeothermal(Heating/Cooling Supply) oResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) . . -
I,Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
['Monitoring DRecovery ft. ft.
Injection Well: -
ft ft.
13Aquifcr Recharge .E3Groundwatcr Remcdiation
19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
['Geothermal(Closed Loop) DTracer 20.DRILLING•LOG(attach additional sheets if necessary): ':' ..;:'.::. ., .
FROM TO DESCRIPTION(color.hardness. ock, e.grain she.etc.)
DGeothermal(Heating/Cooling Return)/ Other(explain under#21 Remarks) ft /'� fl, iUr
ft �,1��, /��, J � C.,4.Date Well(s)Completed:I14' 1 Is -2 1VVe1l ID# 7 ft, d C 4 J -IS7G tr
5a.Well Location:ca ,mod 5 ft 4 b 5 ft 1,1 i J _(4-t �/ f�
i.
21 r l-.r�Y �-1- D i LA b 5' Co-cft. So- )<(ti�!! c,.J ! e•-•
Facility/Owner Name Facility lD#(if applicable) ft ft L .. _ •1
f]�� /^ j/ j/,�/J�s �^ ft. ft. L. '►- );
• l5' C., C cc)1! 'r'` � I• �cL4V� tn..,.1. .+e•._. e. v�,a,
t ft, ft. !! (n�t� n
Physical Address,City.and Zip .N , ( u 7�14` -. 1
c CX �J Cl ZL.REMARKS .. ' Y I
County Parcel Identification No.(PIN) 1r.`:::: :: :-:. " w<.•,.,; ?.j,..
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "`` '``"
(if well field,one lat/long is sufficient) 22.Certification: f
N W ' or
1b-" .
711
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Co Datc
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: 0Yes or 1 }No with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information a 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. i
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-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: C () (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'an 1@l00') construction to the following
10.Static water level below top of casing:40 (ft.) Division of WaterlResources,Information Processing Unit,
If water level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (in.) 24b.For infection 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) / Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above. alsolsubmit one copy of this form within 30 days of
Chlor Tabs 1 1/2 Lbs
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016