GW1--06663_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only: Pr�Itt��
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1.Well Contractor Information:
Robert Teague •
•
:14.WATER'ZONES• 1'
Well Contractor Name FROM TO 'DESCRIPTION
2857-A i ISO>t f e g ft 3i `/. m ,
NC Well Contractor Certification Number f �t ?� ft S '
B&K Well Drillin InC m,
15.OUTERCASING•(formuiti-cal wells)OR LINER Of le)
g FROM TO !DIAMETER THICKNESS MATERIALA
Company Name (� 0 ft Cb D. ft 61/8 in- SDR-21 PVC '
2.Well Construction Permit#:�'f'} l� 6�i 7 '16•INNER CASING OR TUBING(geatherm"at•closed-loop)'
3_ FROM TO 1 'DIAMETER THICKNESS MATERIAL
List all applicable_well construction permits(Le.(i C.County.State.Variance,etc.) fL ft in
3.Well Use(check well use): ft ft• in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESSMATERIAL OMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single)
Industrial/Commercialfc ft J in.
Residential Water Supply(shared) •I&.GROII1: ,`.
Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ft ft.
Monitoring ()Recovery
Injection Well: ft. ft.
Aquifer Recharge . .QGroundwatcr Rcmcdiation ft ft. I
Aquifer Storage and Recovery E3Salinity Barrier :19.SAND/GRAVEL PACK(if applicable) .
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(CIosed Loop) OTracer 2o.:DRILLlNG LOG attacit2ddditeoaai sheets if
Geothermal(Heating/Cooling Return) ( )
[Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardn soierock e.grain sue.etc) _
xx ft. a ";•f. rt , •
4.Date Well(s)Completed: t/'2 'J
Well ID# ({ 2 ft* 6 ' Aco^1/ Ci ('�j•ii- _-
5a.Well Location: ?0�e ft ) a,.C. /� _ ( c Sj�
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Facil`ityty/OwnerN c C �Y) `t l r Facif ID�(ifapplicablc) ft ft.
-%3 J N1 LR't.e4 {l 1- ( ci ft. ft. .; s E` >, : ':l Physical Address,City,and Zip ft. . ....
1.Z C.-b 1 l{/N 21:.REMARKS .
County Parcel Identification No.(PIN)
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: If:,: C•_
(if well field,one lat/long is sufficient) 7.:),..,'` '•" ;" i
22.Certific
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4.1.11 1 a-1-.._ 9
6.Is(are)the weli(s)13Permanent or 01Temporary Signature of Certified Well Contra r
Dan;
7.Is this a repair to an existing well:))(iir
es or IDNo By signing this form,!hereby ccr(/y that the wel!(s)dress(were)constructed in accordance
v.ith ISA.VCAC 02C.0100 or 151 NCAC 02C.0200 Well Construction Standards and that a
If this is a repay,fill out known well coastrurmaiion and explain the nature of the cops of this record has been provided to the well owner.
repair under#2!remarks section or on the back of this form,
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Site diagram or additional well details:
Y"ou may use the back of this page to provide additional well site details or well
construction,only j GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: yJ
� J �� SUBMITTAL,INSTRUCTIONS
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9.Total well depth below land surface: ' `
For multiple wells list all depths ifdifferent(example-3Qa200'and 2(a�I00� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:i
10.Static water level below top of casing:40
ljwater 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 infection 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:,
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
G 1636 Mail Service Center,Raleigh,NC 27699-1636
13s Yield(gpm) Q Method of test: Air Flow 24¢ For Water Supply&Injection'action Wells: In addition to sending the form to
13b.DisinfectionChlor Tabs the address(es) above, also submit one copyof this form within 30 days of
type: Amount: 1 1/21bs completion of well construction'to 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 Resources
Revised 2-22-2016