GW1--06602_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j, .
1.Well Contractor Information:
Robert Teague .. .14.WATER'ZONES •. i •
Well Contractor Name FROM TO DESCRIPTION
kart / ft. jI
2857t .3 L -6L '�ft ,
NC Well Contractor Certification Number
15.OUTER CASING(for �ed wells)OR LINER(if gable)
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft" I C I ft- 6 1/8 in' SDR-21 PVC
n i,„i+.. ^o •1.6.'INNER CASING OR TUBING(getithermal.dosed-loop) • . .
2.Well Construction Permit#: y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance.etc.) fL ft. ! in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1 ,.•, DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) - IBResidential Water Supply(single) ft. in,
Industrial/Commercial Water Supply(shared) ..;
DResidentialPP Y '18:.CROUT. `�; .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft ' •
Monitoring E3Recovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge . . QGroundwatcr Rcmcdiation
19.SAND/GRAVEL PACK(if appileahte) "
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStorrnwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) . QTracer 20.DRILLING LOG(attach additional sheets If necesiary). i .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.ha ess soil/rod(type.grain size.etc)
4.Date Well(s)Completed:'d 1.S 1L4 Well ID# 1 ft.
��'ft � C ri �j{ /�,n1-,�,
A.WellLocatio �05.—[b5-ft...f'16_r'.) G� S0-1___?/
�e.i `g VV`�1 b ft ft.
Facility)Owner Name ac ityID#(ifapplicabc) ft ft i- _ .. ;' "..T-i
1 1) 33 1 16 N ^ .. ..__, e./v-.
ft. ft. 1 s..�.,o.,.;
Physical Address,City,and Zip ft. ft. i Nib V I I
• ♦ .c.. W rA '21t REMARKS
County Parcel Identification No.(PIN) f�•r',t _"•"•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22:C 'flea on: t
N W J I G7�'` to I a1-5 —�[—/
6.Is(are)the well(s) Permanent or E3Temporary Signature of Certified Well Con or Date
By signing this form,I hereby certiiJj 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 15i NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 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 thisipage 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: L,J/� SUBMITTAL INSTRUCTIONS
9.Total welddepth below land surface: et V_ (ft-) 24a. For All Wells: Submit this form within 30 completion days of y p on of well
For multiple wells list all depths ijdifferent(example-3�)a 100'and 2(a7100 j 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.) 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
construction to the following: '
(i.e.au
ger,rotary,cable,direct push,etc.)
Division of Water Resourices,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m
(gp )_1 0 Method of tisf: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1.tl2 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount .• . completion of well construction to the county health department of the county
where constructed.
rii,:�r I
Form GW-I North Carldina•Departmcnt of Environmental Quality-Division of Water Resourcas Revised 2-22-2016