GW1-2021-03399_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teagueia.tivaT>Rzo, s
Well Contractor Name �� FROM).0t. fTO DESCRIPTION
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B &K Well Drilling Inc 3UN X 2021 n rt
NC well Contractor Certification Number -
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2857-A �.3$qo�
re� FROM TO DIAMETER THICKNESS MATERIAL
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Company Name lJV
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�71�j FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Ll
List all applicable well construction permits(i.e.UIC.Gowin•,State.Variance,etc.) f[. R. in.
3.Well Use(check well use): n. fit. in.
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Water Su I Well:
PP Y FRONT TO DIAMETER SWTSI2E I THICKNESS MATERIAL
Agricultural E]Municipal/Public ft. ft. in'
Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) ft ft. in.
W hared
lndustrtaUCommerwalResldenual ater Supply(s ) 1tCtbf
lrrigation -
FRONT TO - NLATERLAL EMPLACEMENT NIETHOD&AMOUNT
Non-Water Supply Well: fit. it.
7.3 Monitoring [DRecovery ft• ft.
injection Well: fit. tt.
Aquifer Recharge Groundwater Remediation
i S :Z:
Aquifer Storage and Recovery OSaliniry Barrier FRONT To NIATEPLAL EMPLACEMENT NIETHOD
Aquifer Test []Stormwatcr Drainauc ft. ft.
Experimental Technology Subsidence Control ft. ft.
PGeothermal(Closed Loop) 13Tracer 29>D1E3RGaC attactiatldilro3iaisheets3#heeess ;;::< ^>
FRONT TO DESCRIPTION leolor.It's.miVrock to c, in size,Me)
Geothermal(Heating/Cooling Return) Other(ex lain under n21 Remarks) rt. rt.
4.Date Well(s)Completed4,;_ Well ID# tt. ft. r. 1 V c V
5a.Well Location: t.
T[�,iU[�►rr �► sbS fit. ft.
Facility/OwnerNatne Facility IDd(if applicable)
`1) f
.St� `L�1�, 1�� >r�ernft. ft.
Physical Address,City.and Zip ft. fr.
County Pared identification NE.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lone is sufficient) 22.Certification:
N W S_
6.1s(are)the well(s)OPermanent or OTemporan ia,aturc o Ccnificd Wctl Cuntrac,! Date
By signing this fibrin.I herelry certi)5?that the xell(s)was(were)consmicted in accordance
7.Is this a repair to an existing well: Yes or No ,ith ISA VCACO2C.0100 ur 15A.NCAC 02C.0200 Well Construction Standard and that a
If this is a repair,ill our known well cnnsiru oti inforinaibn and explain the naittre of he co14,of this reem d has heen provided to the a ell owner.
repair under 021 remarks section or on the bark 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 details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: P SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: fn GS (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple ntiaLs Itst all depths)fdrf(erent(xample-3@2V0'and?(gl00') Construction to the following:
40
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit.
If n'orer level is above casing,we'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 18 (in.) 24b.For infection 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.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) `� Method of test• Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
'13b.Disinfection type: Chlor Tabs Amount: t 1/2 Lbs completion of well construction to the county health department of the county
where constructed. I
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Form Gw-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised,2-22.2016
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