GW1-2021-03494_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague M:W:.kTERZONES
FROM TO DESCRIPTJON
Wel I Contractor Name ! fit. 1 h�
B& K Well Drilling Inc
NC Well Contractor Certification Number �c;ipU 1 ER EASING diaitrcesedisrells DB GIIVER ita' Nb
2857-A FROM TO DL METER THICKNESS WATERIAL
p f[. t_,t .r ft. 6118 i in. SDR-21 PVC
m Company Nac t
\ lrr:::1N?VERCAS1NGOR:`.FIBtNG."eet6eimatcloaed-ioe :
2.Well Construction Permit#: l C:1� .� FROM TO DIAMETER THICKNESS MATERIAL
,n.
List till applicable,,ell consrruction permits/t.e.VIC,,L'buntr,Stare.Variance.et(.) fit• fit.
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricuttural E]Municipal/Public ft k, in.
Goothennal(Heating/Cooling Supply) [Residential Water Supply(single) fI. tt. in. j
indusuiaUCommercial Residential Water Supply(shared)
irrigation FROM TO MATERLAI. EMPLACEMENT METHOD&:N10ITNT
Non-Water Supply Well: ft. tt.
Monitoring DRecovery ft.
In Well: ft. ft.
Aquifer Recharge C]Ciroundwater Remediation
19:SAND/GIt4YEL PACK-41r usable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwatcr Drainaec ft. ft.
PExpertmental Technology Subsidence Control ft ft
hGeothermal(Closed Loop) Tracer 2®:DRILLING:LOG tittsihaddittoiiel::sheets.i€aecevs
FROM To DESCRIPTION color.hardnc%s.solUrodk type.pmtn size,etc)
Geothermal(Heating/Cooling Return) nOther(explain under.21 Remarks)
e. iO ft. c,
4.Date Well(s)CompletedJ— ID# C' t',I
a
Sa.Well Location:
Facility(Owner Name Facility 1D4(if applicable) ft. ft.
l ��Y \� Y ft. it.
Physicaall Address.City.and Zip
L1 " \Ln\�PN��Y\ 21 RRttFetitFc ` I'IY' ,.• t n ,
s Parcel Identification No.(PIN) MAIR
QCi on
County '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iadlonc is sufficient) 22.Cer" ti ll
N W ^c�
Stymaturc of Curtified)VOI Cnnt cloy Datc
6.ls(are)the well(s)�Permanent ar �Tempm•ary
tt tt Br signing this./brit.I herelry certify that the.xeills)xtte(were)constnicred in accordance
7.Is this a repair to an existing well: Yes or IXi No irh 1 iA NCAC 01C.0100 or I SA NCAC 02C.0200 well Construction Srandurdz and that a
Jfthm isa repair,fill out kaoxn well con.simcdon injormannn and explain the nartar of the cope?/this recnr'd has been provided to the x'ell goner.
repair under=21 remarks section ur on the hark of this form. 23.Site diagram or additional well details:
b.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
also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may
drilled: / { SUBNIITTAL INSTRUCTIONS
9.Total well depth below land surface:✓C (fit) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple nrKs 1 w all dept/ts ifd4ferent(:trample-3(eZ,200'and constntction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit.
If water level is ahni•P casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For injection Wells: In addition to sending the fonn 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: constniction 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 test: Air Flow 24c.For Water Supply&Iniection'Wells: In addition to sending I'le form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:
Chlor Tabs Amount 1 1/2 Lbs completion of well construction to`the county health department of the county
f
where constructed.
{
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016