GW1--06702_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only i Prirt1°Fa
1.Well Contractor Information:
Robert Teague
•
:14.WATER ZONES i
Well Contractor Name
FROM TO DESCRIPTION
2857-A /6 b"- 5 4) ft ( h
NC Well Contractor Certification Number ,S aft 3 I�
B&K Well DrillingInc5.OUTER CASING•(for rah Cia welts)OR LINER(if ble)
nc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft �`� ft 61/8 in* SDR-21 PVC
4 (�1)_O� 7 1.5.INNER CASING OR TUBING(geothermal•eiosed loop)2.Well Construction Permit ('� FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State.Variance.etc.) FL it in
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN • •
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
CiMunicipal/Public ft ft- • in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
Industtial/Commercial ft ft in.
Residential Water Supply(shared)
Irrigation i&.GROUT':•>`;•
• ".
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weil: ft. ft
Monitoring QRecovery
Injection Well: ft. ft.
Aquifer Recharge .E3Groundwatcr Rcmcdiation it 1; l
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVELPACK(if applicable) . , •
Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
OStormwater Drainage ft ft• ' I
Experimental Technology oSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer
20.DRII.LL'VG LOG(attach additional sheets ifnccetsary):..;' .
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO :'DESCRIPTION(eator,hard ess soil/rock type grain size.etc)
4.Date Well(s)Completed: I a ft 9-5 ft 8 i lr l L
p `%- —al.4, Well ID# �. i- s ft 2
`` 26 ` h/� J L'1�j.c r�-
Sa.We Location: `KS' t A& ci S ��_! '-'�_
li{� C . ' ft Li '��ft. "' n
Facility/Owner Name
(Facility IDO(if applicable) ft ft. i -�
P�U1 -1Y1(\cre . 7? n_ �+�y �:,e ,t ,
' Physical Address,City,and Zip ft. ft. N U V I 2 C 024
Li i h Ct`Kin 21..REMARKS. —
County
Parcel Identification No.(PIN) ir.`�1 ''�•-''• ;`- "`'tom L r:a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one lat/long is sufficient)
22.Ce .o
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N W
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6.Is(are)the well(s)�Permanent or Temporary Signature of Certified Well Con" for
Date
Data
Yes or NO By signing this form,1 hereby ebrtO that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:
If this is a repair,.fill out!mown well construction information lain the nature of the copy wTt IS .NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
repair under ir:21 remarks section or on the back of this form. ofthis record has been provided to the well owner.
23.Site diagram or additional well details:
8.For Geopr'obe/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 QW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional
drilled: pages if necessary.
• SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: T
For multiple wells list all depths it-different(example- @ a,d (ft) 24a. For MI Wells: Submit this form within 30 days of completion of well
construction to the following:
04
10.Static'water level below topof casing:
Ifwater level is above casing,use (ft.) Division of Water Resources,Information Processing Unit,
6 �$ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
Air Rota 24b.For injection Wells: In addition to sending the form to the address in 24a
12 Well construction method: ry above,also submit one copy of this form within 30 days of completion of well
(Le auger,rotary,cable direct push etc.) construction to the following:;
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program. •
9 1636 Mail Service Center,Raleigh,NC 27699-1636
' 13a Yield(gpm) Method of test: Air Flow �'
24c.For Water Supply Be injection Wells: In addition to sending the form to
t31i;Disinfection type; Chlor Tabs Amount: t 1/2 the address(es) above. also submit one copy of this form within 30 days of
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 ResO urc,z
Revised 2-22-2016
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