GW1--06703_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information: 1I
Robert Teague _14.WATERZONES i I' • •
Well Contractor Name
FROM TO I DESCRIPTION
2857-A J 70 ft. Nft- 50. 6p/Z,
•
NC Weil Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if cable)
B St K Well Drilling Inc FROM I! I DIAMETER THICKNESS MATERIAL
Company Name 0 ft t 61/8 in. SDR-21 PVC
\��• _ -16.'INNER CASING OR TUBING(geothermal:closed-loop)
, 2.Well Construction Permit# �(V Q�l L1 69 ! FROM TO .1 DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Vannce•etc.) fL ft.' in.
3.Well Use(check well use): ft. ft., in.
Water Supply Well: 17:SCREEN ..
A CulttlIal FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I DMunicipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) EllResidential Water Supply(single) ft. ft. ' in.
. DIndustrial/Commercial Residential Water Supply(shared) • ..
['Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. f-
' 0Monitoring 0Recovery ft. ft.
•
Injection Well:
A oiler Rechar a ft. fL,
q g .OGroundwatcr Rcmcdiation
©IAquifer Storage and Recovery Salini Barrier 19..SAND/GRAVEL PACK(it-applicable) .
n FROM TO I MATERIAL EMPLACEMENT METHOD
DAquifer Test DStormwaterDrainage ft. ft.
Experimental Technology [Subsidence Control ft ft.
DGeothermal(Closed Loop) ElTracer 20.DRILLING LOG(attachadditionai streets if necessary). is
Geothenaal(Heating/Cooling Return) FROM I TO , DESCRIPTION(color.hardness. rock type,grain size.etc.)
( gnOther(explain under#21 Remarks) 0 � 1 141 e CA'
S c
4.Date Well(s)Completed:1.0- 1 b-�•L1 Well ID# I tAl ft. )p) S. (1 �r ) /2
5a.Well Location: 1.--
ft. �v ft. 17
\a .11Ne.. 3e i le ft. ft.
Facility/Owner Name Facility[ )applieable) ft ft "'k ,="' . . ' 'F'' t
7 Uft. ft.� A' •� (�
Physical Address,City,and Zip
ft. ft. NOV 1 2 2021
• CN'C W 1 vk2\(Yl MARKS ..
21.RE
County Parcel Identification No.(PIN) C "'"''`-``)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat/long is sufficient) 22.Ce lion:
--)---
N W l� % ,�4
6.Is(are)the well(s)13Permanent or Temporary Si naculc ofCcttificd Well Contract Date
�8
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: es or EjNo with 15,4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been jrovided to the well owner.
repair under#21 remarks section or on the back of this form.
1 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 OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You,may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9• .Total well dept ow land surface: a- (fL) 24a.
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) For MI Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is shove 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
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.auger,rotary,cable,direct push,etc.) I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S 6 Method of test: Air Flow 24c.For Water Supply I&'Injection Wells: In addition to sending the form to
Chlor Tabs 1tz tbs 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. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water i Resources Revised2-22-2016