GW1-2021-06330_Well Construction - GW1_20210915

WELL C QNSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER ZONES
- FROM TO FIESCRTMON
Well 05hiractor Name ft.
B & K Well Drilling Inc ft.
NC Weil('onnactor Cenificanon Number 15.OUTER CASING Form M--t sells WTEM Z*
i cage
FROM TO M.'_IEeT TE
0 ft.15—S ft. 6 1/8 �2 DR-21 PVC
Company Name
16.INNER CASING OR 7 'BING(Stietkiermol closed4oep) .
2,Well Construction Permit#: lt I/. FROM TO DIAMETER THICKNESS MATERIAL
lJvult applic"We i+cfl'onsmwmln peonaT tt.c,1,R.Counn.State.Murivn,c.cre.I ft. ft. in.
3.Well Use(check well use): ft. ft. in.
MSCREEN
Water Supply Well: PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ;Municipal-Public ft. ft. IM
:)Geothermal(I feat ing/Cool ing Supply) V Residential Watcr Supply(sinSic) ft, ft. in.
:Jtndustriaucojmiiercial [DResidential water SUIDPIV(shared) IS:GROUT
MONI TO NIATERM EMPLACEMENT METHOD&..kM. OL',NT
Nun-Water Supply Well:
LJMonitorim! DRecovery ft. ft.
injection Well: ft.
Aquifer Recharge [3Groundwaier Remediation
19.SANDIGRAVEL PACK if avollicable)
Aquifer Stor9ge and Reco%ery [3Salinity Barrier FROM I TO I MATERLU I EMPLACEMENT METHOD
QAquifcT Test Dstonnwaccr Drainage
BExperimental Technology [)Subsidence Control ft,
Geothermal(Closed Loop) 0-f-racer 20�DRILLINGLOG(attach addMekal sheets if necessary)
FROM I TO
MGeothermal Meating/Cooling Retunl) E)Other(explain tinder#21 Remarks) DESCRIPTION(colpr.hardycs,,soit'rock rein sire,ctcl
- — __C) ft. S -5 ft.J- I r�_s_) -3
4.Date Well(s)Completed Well ID# _5 ft ft. 13 2? cc,ir_ 1+-4,
S
Sa.Well Location: R_LS S P'l h6t
I L 6 .5
Facility lf) t1rapplicable)
)C-
ft. ft.
`Physical Addross.City.and Zip 1 ft. ft.
n u-,.VY-Dr,h i S 21.REMARKS
County Parcel Idontificimon No'.(PIN 1.- I-
5b.Latitude and longi
tude in degrees/minutes/seconds or decimal degrees:
(if well field.one IaLilong i,sufficient) 22. 1on"VR So,i.lon
W
6.1s(2.Is(are)the well(s)Mpermanent oi- [3Temporary Signature ofCcnificd Well C;0`111O.'r Date
Br xiganrg the loan. 1 ce,05-thl?l the.X-riko was(.r"6 conpructed in acroidancr
7.is this a repair to an existing well- [)N:es or No
Ifthv his a repair,fill 0111k-P?0M'n V.,dexplain the nature ofihc '"op o0hisreen,d has hcen provided to the v.ell owner.
JyqwirWfdrr IS21 w section ur, the om kof thisNon.
23.Site diagram or additional well details:
e
S.For Geoprobe,'DPT or Closed-Loop Geothermal Wells hat in the same YOU My use the back of this pa�g to prti�ide additional well site details or ikeil
construction,only I GW_I is needed- Indicate TOTAL NUMBER-of wells constniction details. N'ou may also attach addiiiiiiial pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9 s—.Total well deptW_b!f1%land surface. —(ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
Ii.,talldepths it tevainple-31�'00 and 2�'q,WO)
construction to the following:
10,Static water level below top of casing:40 (ft.) Division of Water Reso urces.Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 61/8 (in.) 24b. For infection Wells: In addition to,scriding the form to the address in 24a
Air Rotary above.also submit one copy of t1this form within 30 days of completion of well
11 Well construction method. construction to the following:
(i.e.augt,rotary.cable.(fit"(p.sli,etc.i
Division of Water Resource$,
Underground Injection Control Program,
FOR WATER SUPPLY WELLS(ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
15 Method of test: Air Flow 24c. For Water Supply&ln4i�ction Wells: hi addition to-,ending the torn to
13a.,Vield(gpm) the address(es) abo,e, also submit one copy of this form within 30 days of
I-3b.Disinfection type-. Chlor Tabs Amount: I-112 Lbs completion of Nveti, constructiod to' the county health department of the county
where constructed.
Form OW-I Norh Canil ina Deparlinent of EncironreninI Qua h i y-Division of Water Resoite I c's Revised 7-22-201 it