GW1-2021-03400_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information: y�a�
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.Robert Teague
Well Contractor Name FROM TO DESCRrPT ON
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B & K Well Drilling Inc
NC Well Contractor Certification Number �l
pIOr,E,ncS1lQf�u 1COIxTEIiGeiS7NG maftPcased;i4e CdR': tl ' lieiifr
2857-A r,r ;�i10n1p ,, On FROM TO DIAMETER TDICKNESS XkTERIAL
iCt{J 0 ft• 6 1/8 in. SDR-21 PVC
Company Namc \ /? 1 - - ---
1� �'l T7 1fi.ISvNL1t.FkSll�tt{)R?iSBSDtM eblie�malTHIC THICKNESS
2.Well C0n5trDr17Dn Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State. Variance,ctr.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
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Water Supply Well: FROM TO .....DIA M ETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)MunicipaUPublic ft IL in.
Geothermal(Hcating/Cooling Supply) NcesidonLial Water Supply(single) ft- R. in.
Water Supply shared nal S e idea )
a rercial Rs Ind ter UComn (!n s y� PP YWX
irri ation FROM TO MATERLAL EMPLACEMENT METHOD&AMOUNT
Nun-Water Supply Well:
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Stor9ge and Recovery [)Salinity Barrier _ FROM TO a1ATERIAL EMPLACEMEYT DIETHOD
Aquifer Tcst []Ston-nwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ;:29ED1t1I E3PrI Cam'attack:additEorieEstieeis=iE " ?: :;'z:>_[2>!s >:;: f:;;»;i;i:::;E<: .
Geothermal(Heatin&Coolin Return) Other(explain under 92 Remarks) FROM To EsexlrnoNcaor. cress WI/rock t. rnfn sac,tier
4.Date Well(s)Completed-5-1 Ll- Well ID# �Stt• ft. &r
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L ft.
52.Well Location: wk
rt. ft.
Facility/Own Name Facility 09(if applicable) ft. ft.
ft. ft. _
ft. it.
Physical Address,City,and Zip
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County Parcel Identification No.IPiN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 7"+
(if well field,one lat/long is sufficient) 22.C¢r' CatiO
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6.1s(are)the wells) Permanent or OTemporary Siptaturc ofCertified Wcl1, ntrdctor Ddtc
b signing this form.1 hereby certify that the we./1(s)sums two-0 cotutnicted in accordance
.7.Is this a repair to an existing well: es or []No nirh 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Cunsrruction Standards and their a
Jfthis is a repair•ell out known well con.stnectt rt in nat/on and explain the nature of the coin'of this record has been provided to the sell om er.
repair under S21 remarks section or on the back of this,farm.
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 details. You may also attach additional pages if necessary.
constniction,only 1 G W-I is needed. indicate TOTAL NUMBER of wells
drilled: 5 C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _, (ff•1 24a. For All Wells: Submit this form within 30 days of completi•_ii of well
Far multiple ur/A/W all depds if different(trample-3@,200'and 3C/00') constniodon to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If.carer level is ahave.casinA-Ur e +, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1 18 (in.) 24b.For iniection Wells: in addition to sending the form to the address in 24a
Air Rotary m above.also submit )ne copy of this for within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct pusli,ew.)
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 test: Air Flow 24c-For Water St1DDIV&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form iv'ithin 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construcriou to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revis:,e.2-22-2016
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