GW1-2021-05722_Well Construction - GW1_20210706

a .2,
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
t
Robert Teague ��� M-wAT1R zoiv�s"
Well Contractor Name FRONT 7O DESCRIPTION
B&K Well Drilling inc
�U� p � 2021 ft. ft
NC Well Contractor Certification Number iS..E)$3[ERCAti!I'Gtor_multacased:i3Bltst)R:i1fwgR'itis licnble
2857-A �'(PCOCe&Sing l dlk FROM TO DIAMETER THICKNESS MATERIAL
o it. t s ua SDR 2f PVC
CompanyNamc Q
(/�-
� �'16 1.N1NElt S1I�G:�.G+A Z{lBftilC� Petberinaf ctased=ioo ...:.,�
2.Well Construction Permit#'3—k 3 C;A=`— FROM TO DIAMETER THICKNESS MATERIAL
14sc n11 applicable Nell consmiction permits ff.g UiC.(;oulm"Stoic,Variance,etc) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: t7:SCR£E19.
FROM To DIAMETER SWT SIZE THICKNESS MATERIAL
Agricultural E)Municipai/Public ft ft. in.
Gwthci,nai(Hcatine/CoolingSapply) csidcntial Water Supply(single) ft tt In
Residential
Industrial/Comniereial Water Supply(shared)
Irrigation FROM TO MATERML EMPLACEIN ENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
monitoring DRecovery ft. ft.
Injection Well:
tt ft
.Aquifer Recharge nCiroundwaier Remediation
;19>SANiN.+wRiltiELiYAC1C f a ble}:< _ .> .......-
�iAquifer Storage and Recovery [3Sahnity Barrier FRONT TO I MATERIAL EMPLACEMENT METHOD
Aquifer Tcst [)Stonnwarcr Drainage
Experimental Technology Subsidence Control ft. st
Geotherma)(Closed Loop) [3Traeer 29:.DRIEGINfi1(lL itusehaitdttronetsiieets>#
FKONI TO DESCRIPTION c tor.ha Oct&soRfrocic ri 0. rain sue,eta)
GGeothermal(Heating/Cooling Return) Other(ex lain under 21 Remarks) ft. j- ft. J
4.Date Well(s)Completed: Ire-)��Well 1D# I LI t ��
Sa.Well Location: ft. ft. a
` y ft. ft.
i• }�l`1
Facility/Owner Nanie ) yF/a6t iry lDe'0f applicable) ft. ft.
Physical Address,City,acid Zip
ZL.REfiit1RKS`.:
-- �\ Al '7&3lylySS
County Parcel identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif-icationn-�: "}
N 'G" ��'
6.Ware)the wr il(s)jiPermanent or Temporary Sigilut�uf CCcriificd Well Conuactie Date
Bp signing then fOrlfl. 1 17C1'C(n7 CCTI(y that the wC11(f/ivat(were)consrntcred in accordonce
7.Is this a repair to an existing well: es or E)No ii iih 15A tiCAC 02C.0100 or lJ4 NCAC 02C.0200 Well Construction Standards and that a
1(rhis is a repair,Ill urn btoam well cnnsauc on in�[rrination and explain the nature ofthe coin'ofihis rernid has heen prnvidcd to the well owner.
repair under.421 remarks section or on ike hark q(this(arm. 213.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
constriction,only I rW-1 is needed. indicate TOTAL N UMBER Fof wells construction details. You may also attach additional pages if necessary.
drilled: ( / C SUBMITTAL INSTRUCTIONS
9.Total)veil dept below land surface: -1 ✓ (ft-) i
( 2aa. For All Wells: Submit this form within,30 days of completion of well �
For niultiple+vehit list all del:tln{(dt•'lfereni(aaniple-3@4Q00'and 2@)I0(Y) construction to the following: j
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
!(water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) tab.For Infection Wells: In addition to cnding 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.) i
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&Injection Wells: bi addition tti sending the font[to l
the address(es) above, also submit one copy of this form within 30 days of
Chtor Tabs t 1/2 tbs completion of well construction to the coup health department of the coca(
i3b.Disinfection type: Amount: P n' P h
where constructed. 1
4
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised'_-2_2-_2016
i