GW1-2021-06307_Well Construction - GW1_20210915

A:
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZO-.NES
FROM TO BESCRTPTION
Well Contractor Namc I 1 ft. 3
B & K Well Drilling Inc tr
ft.
NC Well Contractor CeTlification Number
15.OUTER CASING(for OR LINER'Jif a
2857-A FROM TO T, NULTERJAL
D ft. "—) so
ft. 51/8 in. I R-21 PVC
Conipafty Nanic [:C
16,INNER CASING OR I ''BIND Wethermal ilmd,loev)
2.Well Construction Permit FROM TO DIAMETER THICKNESS MATERIAL
Liso'llapplicable siale.vcirivniv. :1­j ft. f6 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Weill: FROM TO OIANIETER tiLOT SIZE THICKNESS MATERIAL
7)Agricultural Olvlunicipal<Public ft. ft. in:
:)Geothennal(Ficating/Cooling Supply) 9)Rcs;dcnii JI Watcr Supply(sine1c) —
ft. 11.
:]JIndustrial/Commercial Mesidcntial Water Supply(shared)
t8.GROUT
Irrigation FROM TO MATERLALL ENIPIACE%JENT METHOD&.1LMENT
Non-Water Supply Well:
73\11onitoring fL I'L
Injection Well: ft. ft_
P-AclitiferRecharge nGroundwater Remediation
19.&&ND/GPLAVEI,PACK fit applicable)
PAculifer Stor -e and Recover} Salinity Harrier
FROM TO INIATERLAL EMPLACEMENT METHOD
DAquifer Test Dston-nwatcr DrainaLc It, ft.
E,\p efiniental Technology DSubsidence Control It, ft.
:1Geothermal(Closed Loop) Tracer 20.DRILLING-LOG-(itttachaddMoi2stshmts-iroetmaryI
73Geotherma)(14eating/Cooling,Return) r)Other(explain under 421 Remarks) FROM TO DESCRIPTION(color.hardnifs.sollirockofic.Itruin sly.c.etc.)
irA KCD
4,Date Well(s)Completed:%..:—? Veil ID# _57 C\
5a,Well Location: it, ft.
Vft. ft.
Facility-rOwner Nam! Facility ID (irapplicalk) ft. ft.
U,3� -- ft. ft.
Physical Address.City.and Zip
Dck\ \e 5 21.REMARKS
VP V 0 P,
County Parccl J&nfif`ic;!iion-No.t PIN) 0
5b.Latitude and Ion-itudc in degrees/minutes/seconds or decimal degrees:
(ifwcif ficid,one favlone ii sufficicni'l
22.Certift
N W
6.Notre)the well(s)0 Permanent or [31[emporary
4v cignine thisjorm. f hcrrin-cerqt.r that the I,rilKo Iva.,(urre)cm1pnicied in accardancr
7.Is this a repair to an existing well: E)Yes or No iilh 1.5.4A C�4C 02C.0140,p IJA AC.4C 02C.0200 P,c/I Construction SwndariI5 anal thattj
No
l(rho a a tepair,fill our bw­i.-ell,eimimcfiem btJorrriomr r cxpledn!hc nowic efihc copy'of tk,ircn,d has heat pmvided to the v.r/l owner,
retwir lwdcr relpldf-AI"VC tion ur w 1/1"Burk vlth;s furni,
23.Site diagram or additional well details:
S.For Geoprobe,'DPT or Closed-Loop Genthermal Wells ha,inn the same You may use the back of this page io provide additional hell site details of %,,!It
constniction details. 't'ou may alto attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL N U\48ER of wells
drilled SUBr*II1J'AL INSTRUCTION'S
9.Total well depth below land surface-.. —(R-) 24.. For All Wells; Submit this form within 30 day, ot'completion of well
Fn,.nwhilyle-,ell;fin all depths ifdi0rem wrawpte- '00*and 264;100')
construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources.Information Processing Unit.
ll'iorrr lei-pi is abrove cavhf_g use­,- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 61/8 (in.) 24b. For Infection"Is: In audition to ;ending the fon-n to the address in 24a
Air Rotary abuts, aku submit one cupy of this form Ivithin 30 days of completion of well
12.Well construction method. - Construction to dle following)�
I i.e.auger,rotary_cable,du,:,a push,elej
— Dkisiori of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Yield(gp-) Method of test! Air Flow 24c. For Water Supply&Iniection Wells: In addition to sending the fonn to
Chloe Tabs Amount: 1 1/2 Lbs the addressites) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
Bla;Disinfection type:
where LonsIMUcd.
F"nJ ow-I Norill Carolina Deparnnew o F Environnicnial Qualvy-Division of Water Resoi�rces Revised 2-22-2016