GW1-2021-03394_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague a 14 9YA7ER{Z91 +
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Well Contractor Name ei' � FROM TO DESCRIPTION
�� � te6Sft. `-0 ft g
B &K Well Drilling Inc
NC Weli Contractor Certification Number U 1 ?'
8.- 1.)131t TS_OF!'FERCi1iS1NG: ";tlinitt-cesed:ltielh lIIt1::I}tF7?ft •':
2857-A �`�f©O �SIIF(� FROM ft, TO ft• DIAMETER in, THICKNESS MATERIAL
�f� ` 0 61/8 SDR 21 PVC
Company Name p
ifk;INl'E E`AS1NGE3R Fxm3CiG 'Ee15exnaLel'osed lbe
2.Well Construction Permit#: C Oy� FROM I TO I DIAMETER THICKNESS M.aTER1AL
Lrsf all applicable cell construction permits(i.e.UIC Coutn?,State,Variance,etc.) ft ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SWT5IZE THICKNESS MATERIAL
Agricultural *Residential
unicipal/Public rt ft. in.
Gcothennal(Hcating/Cooling Supply) Water Supply(single) it ft. in.
Industriaucommercial esidential Water Supply(shared) (;RAI3T
irrigation FROM TO DL�TERLAL EMPLACEMENT METHOD&AMOTJNT
WelkNon-Water Supply Welk
rt. it
Monitoring ORecovery
Injection Well:
Aquifer Recharge r.lCiroundwater Remediation
i�i�a1vl�itnv`�L�t1;c1e' b1
Aquifer Storage and Recovery Salinity Barrier FROM To AUTERLAL EMPLACEMENTMETHOD
Aquifer Test DStormwatcr Drainage ft. ft.
Experimental Technology []Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 21i SlRIiE3p!iGtUC:attachaddinSiie#slreeWt. 1.
FROM TO DESCRIPTION color, ness Sol Vroek n In sezc,etc)
Geothetmnal(Heating/Cooling Return) Other(explain under#21 Remarks) ft ft G CK,
4.Date Well(s)Complet 3- 11 Well ID# ,��tt. e1 t� ft. C' } 1/G )
Sa.Well Location: Sic' 3 e).5
ft. it
Facility/Owner Name Facility IDk(ifapplicable) ft. ft.
of
ft. ft.
ft. ft.
Physical Address,City,and Zip
County Parcel identification No.IPiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifte n•
N W
Sigua uis:of Certified Wcll Contractor Dat.
6.Is(are)the well(s)OPermanent Or OTempot-ary
By signing this form.1 herelry certify that the well(s)was(were)consrrucred in accordance
'7.Is this a repair to an existing well: Dyes orNo � �ith 15A NCAC 01C.0160 or I.iA NCAC 02C.0100 Well Construction Standards(Ind that a
Ifthis is repau'..frll out knos+m well construction information nG d ezplain the nature o(the cope'af/his retard has been provided[a the xell ow er.
relu+ir tinder 011 renu+r6-s section ar um the Kruk ujthis,fornn. 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 details or well
constntction,only I GTW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: '1 SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 3 Va (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple ur11s list all deptlu ifdrjfereni(eample-3@200'and 2 a,100') construction t0 the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,information Processing Unit,
if watpr level it above casing,use 4-'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6118 (ia) lib.For injection 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.etC.l
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 tes Air Flow 24c.For Water Supply&Injection Wells: In addition to senduig*th form to
C
the address(es) above, also subrnjt one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 112 Lbs completion of well construction io the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-21016