GW1-2021-06653_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD (GW-1) For Internal UseOnly: j
1.Well Contractor Information:
Robert Teague ��� :M:WATERZONEi
FROM TO DE.SCRTPTION
Well Contractor dame
B& K Well Drilling Inc �UL 2021 r `' rt Z
NC Well Contractor Certification Number d tt pro FROM
if>UUTERCASIkvG to>tiidltt.cased.:irelh UR:LINER eta a51e1
2857-A tii$'Im3boT,pr ^t FROM TO-.aDIAMETER THICKNESS MATERIAL
�"SeC�"On 0 ft. f[• 6 118 in- SDR-21 PVC
Company Name 16.1NNER G iS1NG i3R TUBING:"eetbermat<closed itro
'.Well Construction Permit#•J w QI OLI FROM I TO DIAMETER THICKNESS MATERIAL
Test tell applicable.,ell consnvction permits(i.e.Ci1C'.Cowin%State.Variance,etc.) ft. ft. in.
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM I TU I DIAMETER SWT SIZE THICKNESS MATERIAL
Agricultural OMunicipaL/Public ft ft.,
Geothermal(Heating/Cooling Supply) nResiticniial Water Supply(single) fL ft in.
Ind ustriaUComnuereial esidential Water Supply(Shared) lgRt, ; ;,. ....::...
Irrigation FRUAI TU M.ATERLkL EMPLACEMENT METHOD&.If.MOt1NT
Non-Water Supply Well:
Monitoring nRecovery ft. it-
injection Well: fc. ft.
Aquifer Recharge C)Ciroundwater Remediation
per, .I9 SetiVDIERAVEf.,PACK'(lf `"tite}
Aquifer Stor#ge and Recovery [3Saliniry BalTier FROM TO n[4TERL4,L EMPLACEMENTMETHOD
YAquifer Test [3Stormwatcr Drainauc ft. ft.
Experimental Technology Subsidence Control ft.Geothermal(ClosedLoop) Tracer 2@:T3RTIEiNG#'OCfAtl It,liaddine" at:sleeetsl€:neceaa
FROM TO DESCRIPTIO`N1 color,hardness soitroct.n c, rain . c[e-1
!Geothermal(Heatine/Coollii'ng Return) Other(explain under#21 Remarks) ft• r Cd rt• / •� 7� _
4.Date Well(s)Completed{:: V�� Well ID# I Q n. �' R. h _1 c 0, \
ft. ft.
Sa.Well Location: `
c rC N s c�Nl So ht� R.
FacilitylD4(ifs livable)
L ft. ft.
�Facility/Owner Na\n1a ) _ PP f��l�l ft. ft.
fr. ft. i
Physical Address,City,and Zip
2tint �irtlU�
County Parcel identification No.MN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer�flfc
Signature:of Cenified Yrell Contractor Datc
6.Is(are)the well(s)OPermanent or 13Temporary
By sigaDtg this fora[.1 hrrelnv certify that the welIK0 was(u•et•e)ennttntened in accordance
7.Is this a repair to an existing well: [)Yes or No +,irh 15A NC.4C 02C.0100 ar 154 NCAC 02C.0200 well Construction Standards and that a
Ifthis if a repair,fill otn known well consiniction i?ifnrinai;e)na?iX explain the nanav ofthe cope ofthis recnrd has been provided to the well o—er.
repair under 921 rrntarG-s section a',the back ofthis f rm. 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 ppDvide additional well site details or well
construction.only GW-I is needed. Indicate TOTAL NUMBER of wells
constniction details. You may also attal;h additional pages if necessary.
drilled: Q _ SUBAiITTAL INSTRUCTIONS
9.Total well depth land surface: 1 t/ —(ft-) 24a. For All Wells. Submit this form within 30 days of completion of well
Fnr multiple well.(list all depdts if lent(uample-_(Ic]l10'and>C/00') construction to the following:
10.Static water level below top of casing:40 Division of Water Resources,Information Processing Unit,
Iftrvrer level a above casing,we-" 1617 Mail Service Tenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1 r8 (in.) lib.For(niection Wells: in addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary.cable,direct push.ete.l
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service`enter,Raleigh,NC 27699-1636
13a.Yield(gpm) ` Method of test: Air Flow 24c•For Water Supply&Iniectioa Wells: Inaddition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs 1 1/2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type: Amount: P
where constructed. f
Form GV.`-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016