GW1-2021-06285_Well Construction - GW1_20210915

WELL,CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information: 1
b
Robert Teague y I4.waTER zoNEs
ROM TO DLSCRrPTION
Weil Contractor Name A. (N
. •ft. aft. /
B& K Well Drilling Inc C�Q �v, 3114
��� e
NC'tv'el!Contractor Certification Numbe' AN
' �O Cj 15,0VTERCASiNG(for 6rulti-e" ".4vells OR LIN"1 R<il'fi lieable >:
2857-A �� 34��� FROM TO DU9IETER THICt:NESS MATERIAL
Ii 1l D ft. Gila f in. SDR-2t PVC
Company Nano I
16.INNER CASING:OR?Lt31NG eetbe:malclased-too
2.Well Construction Permit#' ! 1 FROM I TO DIAMETER I THICKNESS I MATERIAL
Lisr all appiicuh/c++'ell ronsrnrerwi permit,ti.u.1.1(.Caunnt$rare, iurian:e,eic.i ft. I in.
3.Well Use(check well use): ft. ft, in.
Water Supply Well: FROM
SCREEn.
FROM TO DIAMETER SLOT SIZE THICKNESS, MATERIAL
Agricultural Municipal/Publk: ft. u- in-
Geathcnnal(HeatingtCOoling Supply) Residential Water Supply(single) in.
Ind rstriali"Commercial t esidemial Water Suppl.%(shared) i 18.GROUT ,
Irrigation FROM I TO MATERIAL EMPLACEMENT NffTROD&Bo.AMoLrNT
Nun-Water Supply Well:
N9onitoring RecoNc y
Injection Weil:
ft, ft.
Aquifer Recharge 106roundwater Remediation
19.SAND)GIUVEL PACK if a hicable
Aquifer Stut,9ce and RxO cry DSaliniry Farrier FROM TO MATERIAL EMPL.ACEMEVTDIETHOD
DAquifer Test DStonnwatcr Drainage ft. ft.
:)Ghperimental Technology E)Subsidence Control ft, ft.
:1-Ci+lotherma)(Closed Loop) IDTracer 20:DRILLING LOG"(attach additlenal.sheets ifnecessary)
Geothermal(Heating/Cooling Return) n0ther(ex Lain under 21 Remarks) FROM TO DESCRIPTION icolo,ha ess,toili+ock n nin size,etc)
\ ft. ` ft. 6
4.Date Well(s)Completed: - - well ID# tt' hilt G -
s,
5a.N',cll LocatZn:, \�
Facilityiiowner Na= Facility lDz kfarplicable) ft. ft.
physical Address.City.and Zip ft, ft.
21.REMARKS
L,�
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
firwcil field,one la0cing is.:ufficieno 22.CertificaIto :
N. W J
6.Is(are)the well(s)(x Permanent or Temporary S+gnaft c of Certified Well Contr r Date
1 Bt signing this form.1 heron:cei-ih'that the wa lw carte tivere)cowrructed in accordance
7.is-.this a repair to an existing well: Oyes or No +!iih L,,4\C IC 02C.0l+k)oi'1 AA ACAC 02C.0200 w41 Cumiraerion Standard.,and that a
if'thi.{is a repair.T/l our known Nell rnnQntctimt;Nnrmoiinn and explain;hr nature of ro/?t n/ihi.e record hat hecn provided 10 the x"ell oicner.
repair ands'P21 remarks xvrtion ur m the bank of this lurnt.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells hat ing the same You may use the back of this page to provide additional well site details or i,ell
construction,o 1 1 GW-I i�needed. Indicate TOTAL i UMBER of wells cunsintction detail;. You may alto attach additional pages if necessary.
dolled: ✓1 SUBMITTAL.INSTRUCTIONS
9.Total well depth belo»land surface:_ 4i J (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For nrulrip!e+rfll.+6.+r all dfpdtc i1 diflereni rarronp/r-::'d 00'and_64,100') consintction to the following:
10.Static water level below top of casing:40 Division of Water Resources.Information Processing Unit,
it"ater heel ix above coring.n,e"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1 J8 (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: constnuction 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-I636
a
13a.Yield(gpm) r Method of text: Air Flow 24c. For Water Supply&Iniection Wells: bi addition to sending the fonn to
the address(es) above, also submit one;copy of this fftonn within 30 days of
I3b.Disinfection type: GhlOr Tabs Amount: "')z tbs completion of well construction to the GOtlnty health department of the county
where constructed.
i
Form GK'-i Nor Carol ma Depart nent of Envirvnmenta)Quality"-Division or Water Resources Revked 2.22-1016
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