GW1-2021-03496_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague 14::w.ATERZONE$
FROM TO DE.SCRTPTION
Well Contractor'Name - / 5 t /�ft
B&K Well Drilling Inc / rt. rt.
7O
NC Weil Contractor Certification Number IS;OtT..ER CASING 'niiiltm easid rclh OR'hl4VE1t tl< cab'
2857-A FROM 70I DIAMETER THICKNESS MATERIAL
0 f[. ft. 6118 in' SDR-21 PVC
Company Name
16:.lNNERG1S1NG:+3R:F03g1NC: 'etAet>5i-cldised-to6 ._':
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
.List all applicable Me/1 Cowimcdon Permits/i.s:. ?IC. '01411-t State, Partance,etc.) ft. ft. in.
' .in.
J.Well Use(check well use): ft. ft.
Water Supply Well: FROM TO DIAMETER SL.OTSIZE THICKNESS MATERIAL
Agricultural )Municipat/Public ft. e. in.
Geothernal(Hcating/Cooling Supply) esidcntial Water Supply(single) tt f in.
IndustriallCommercial esidential Water Supply(shared)
l$siGl 6U _ ....
lrri,-anion FROM TO MATERLAL EMPLAC9"T,:ME .DB.AMOLTNT
Nun-Water Supply Well: ft. tc.
Monitoring DRecovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge 0Groundwatcr Remediation
19..SAND'/GRAVELPACX:ifa bcable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERLAL EMPLACEMENT METHOD
Aquifer Test [3Stornwaccr DrainaLc ft. ft.
Experitfiental Technology 0SUbsidence Control ft ft
Geothermal(Closed Loop) DTracer 29£DRIIfLa1G3OG itttaihaddihurietslteets.if:necess
FROM TO DESCRIPTi0N color rdnta<so roeLri rom srzc del
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. 5 R.
4.Date Well(s)Complited:S- aXA%, ,W'ell ID# S ft.
IN; a� ^��C
5a.Well Location: O >ft. ft-
44
G
M � Ne AZ5 .1)^�ey 1Gr^c� ft.
FacilityjiO`wnrrNatnr p( FacilirylD (ifaoplicable) ft• ft. p
ft. ft.
`a1 �\z . t o V e
Physical Address.City,and Z
21 RE113ARK5 is
It >:
County Parcel identification No.(PIN) ye ;,�,�,
1`ify011:3 tQ n
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: AmNR
(if well Held.one IatJlonc is sufficient' 22.Ceyt1 1
6.ls(are)the well(s)oPermanent or OTemporary
S_mature ofCeriticd We ontrac or Date
t Br signing this form 1 herrl.v certify that the Nrllcc)was tx•ere)comintcted in ccordance
7.Is this a repair to an existing well: Yes or.f 7�n ,t ith 1 SA NCAC 02C.0100 up 114 NCAC 02C.0200 well Construction Standard.:and that u
copy ofthis record has hecn provided to the v.ell oicner.
ifthis is a repair, ll out known Nell consi ucnon in/imnaunn and rx ain the nature ofthe
repair under 021 remarks smtiun or on the hark of this 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 provide additional well site details or well
construction, 1 GW-I is needed. IndicaTe TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 04, SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `' (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple,rr/ls list all depths it dijferrnt(example-=Cat00'and 20a,/00') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
ifn'ater level i.c ahnre casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 On•) 24b.For iniection 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 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 the foil[to
the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs 1 v2 Lbs comp letion of well construction to the county health department of the county
13b-Disinfection type: Amount: P
where constructed.
6
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016
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