GW1-2021-05724_Well Construction - GW1_20210706

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague
i14:OSS?ei'GR ZOtVI✓'S.
FROM TO DESCRTPTTON
Well Contractor Name ft. ' 7/ tt• ) )f�
B&K Well Drilling Inc ft. , ft. `
NC Well Contractor Certification Number 15 OUTEifG457`rG mutt+ciised tiel''a3R 111�1 fT`ir. lieafilel
2857-A FROM TO DIAMETER THICKNESS MATERIAL
o (t. V ft• Bt/B� �• SDR-2t PVC
Company Namc 16.
INNER:t*511tG'U1Z IUSiNG estiei'iiialclosed= ''
Z.Well COnSITUC1iOn Permit#: — FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well coowmction permits(i.a.Urc..Comim,State.Variance,etc.) ft. in.(t.
3.Well Use(check well use):
li7•$C1tE£Nf
Water Supply Well:
pp y FROM TO DIAMETER SWTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft ft.
Geothermal(Heating/Cooling Supply) Residcntaal Water Supply(single) ft ft, in.
lndustriatiCommercial Residential Water Supply(shared)
.. '::LB:GRlDU3°i
irrigation FROM TO MATM&L EMPLACEMENT NfETHODdAMOMT
Nun-Water Supply Well: ft. u.
Monitoring' nRecov'ery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E]G'roundwater Retnediation
I9 S LiV1)Y.G1L1VhJ:1'fICK{tf "licatitel
Aquifer Storage and Recovery DSalinityBarier FF
TO PLATERLAL EMPLACEIv1ENTMETHOD
Aquifer Test [3Stolmwaccr Drainage ft
Experimental Technology Subsidence Control ft
BGeothermal(Closed Loop) Tracer NGL-UG:atkkft*A ditlonetslceeisafnecess
TO DESCRIPTION color, rdness-sotUrod,b a In�.a:r,ctel
Geothermal(Heating/Cooling Return) Other(explain under n21 Remarks) - tc. t
.5 i , r J
4.Date Well(s)Completed: �- Well ID# G ftll Loc Boni: �7c. f•1�, t� •�G f- C—
Facility/Owner Name Facility 1D4(i'ffapplicable) ft• ft. g f +1
S / 1'1 1 1�`o..-!c �ti�.t(� C'`\i`•!� 1 ` C�r���y�_� ft. tt. --
Physical Address,City-and Zip rt. ft
• County Parcel identificati n No.(PIN) _..,.r
i, rZ eciion
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiftea
SiRmaturv;of Ccnificd Wcll C muacnjr Datc
6.Is(are)the well(s)IgPermanent or Temporary
By signing this(orn.1 hereiry certifj•rho,the xrll!s)was(x'cre)corarnicred in accordance
7.Is this a repair to an existing well: [)Yes or ONo o.ith 15A NCAC 02C.0100 or IjA NC.9C 02C.0200 well Construction Sttmdani)and that n
Ifthia is a repair,fill our knoxat well can.suuction information and explain the native 0.0he cops'of/his reenrd has been provided to the,ell ovrner,
repair under 921 remarks section ur on the hnek of this form. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site det vls or well
constriction,only I('iW-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: -L-) —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Few multiple uriLt list all dryuhs ifdylerem(example-3Cea!201J'and 2�,100'1 Construction to the followinn:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Uni,
Ifwarer level is above casing,use"+" 1617 Mail Service Center,'Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For infection Wells: iII Iddition to scrtding the form to the address in 24a
Air Rotary above.also submit one copy of this fomu 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 vest-, Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the torn to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type:
Chlor Tabs Amount: t 1/2 Lbs completion of well comrrucuon to the county health depaitnent of the county
where constructed.
Revised'_-?:-_'O1 ti
Form C*t1'-I
Northpa Carolina Department of Environmental Quality,Division of Water Resou,ces
I