GW1-2021-06336_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For lnlemal use Only:
i
1-Well Contractor Information: E
r
Robert Teague M WATER ZONES
FROM TO DFrCRrP,TION
Well Contractor Name I
�ft. ft, j.
B&K Well Drilling Inc ft ft
NC Well Contractor Cenilication Number 15.OUTERGASING for:mdlL•cistsd:iwells OR L111IEt£ii 1
Z8S7-A FROM TO DIAMETER THICKNESS MATERIAL
o ft. ( t• o t/8 t 'in. SDR-21 PVC
Company Name 16:INNER CAS Gt:3R.T:UBiNG eelhertnat closed-loe
2.Well Construction Permit#: (> 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cunsnvetiar pe»Hitt/i.e.Lek'.lbunn,.Stour,Vuriunre.er<'.1
ft. ft.
in.
3.Well Use(check well use):
tiiSC32EEN ''
Water Supply Well: FROOI TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural �MtmicipahiPublic ft. rL in:
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL in
lndustrialiCornmercial residential Water Supply(shared) 18:GROUf
Irrigation FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it- ft.
17IMonitorin,, DRecovcry•
injection Well: it. tr.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVELPACK if ticable
Aquifer Stordge and Recovery [DSaliniry Barrier FROM TO ALATERLALL EMPLACEMENT METHOD
Aquifer Test []Stonnwater Drainage ft. ft.
Experimental Technology C)Subsidence Control ft. ft.
othermal(Closed Loop) 1 racu 140 DRILCINC f
Cn SG>(attach add;tiolielsheeb ithecessary'.
FROM TO DESCRIPTION color-harldnli%s,soiltrooA a c. rsm srzc Mc)
Geothermal(HealinrJCooline Return) Other(explain under 21 Remarks) R R
4.Date Well(s)Completed• 9- Well ID# • f
52.Well Location:
A/ ft. ft.
Facility'O Facility ID=(if applicable) fr. ft. -
ft. tt. µ
S 10
fr. ft.
tie V
Physical Address.CiL.and Zip C�
A�,r�,l h 1 x n f 21.1tEbiARKS
Parcel identificati N PIN on o.( )
County
r�r sg 1l011
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaClom_is sufficient) 22.Certification:
N W
Slguatnw ufCertificd Well Contractor Datc
6.1s(are)the well(s)ox Permanent or OTemporarc// Br signing this fnrnr. 1 herein:certilj that the xrlltaj 1V2e(xrr'C)COIl.Vnlfted in accordance��,,
7.Is this a repair to an existing well- [3Yes or i ,ith 1 s.9',GIC 02C.0100 ur 15.4 NCAC 02C.u200 hell Cummrructiun Standards and that it
1f this is a repair,T/1 nor known well ennsinection hilorman.nit a lain the nauav nfthc coin'ofthis reenrd has been provided to the xrll mvtrir.
repair under-'21 ronat•ks section ur on the back ul 1his form. 23.Site diagram or additional well details:
You may- use the back of this page to prot ide additional v ell site details or ell
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells hat in,,the same
y
consiniction details. you may also attach additional pages if necessary.
constnuction,onl GW-1 is needed. lndicate TOTAL NUMBER of wells
drilled: SUBh1ITTA1.-INSTRUCT IONS"
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr nrrt/tiple r,ell,liar all depilrc if different toramph-=_2'00 and--'idr/rlt/'I constnuction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If carer level is above casing,use-+"' 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter. 6 1/8 (in.) 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 eta)
Division of Water Resources,1Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
PL (
13a.Yield(gpm) Vim./ Method of Lest: Air Flow 24c-For Water Supply&Injection Wells: hr addition to sending the form to
the address(es) above, also submit one copy of this fonn within 30 days of
Chlor Tabs Amount: P2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type:
whcty constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016