GW1-2021-06361_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Of
1.Well Contractor Information:
R4bert Teague 14.WATER ZONES
%Velr,(owractor Name FROM TO I DESCRI"PTION
B &K Well Drilling Inc
ft.
N('Well Contractor Certification Number
15,OUTER CA']N"f 1!alfic*sPd wells)PR LINCR`gfip livable)
2857-A MR011 TO' uLA METE, THICKNESS M.%TERIAL
0 ft. ft. SOR-21, PVC
Company Nanic i
I&INNER CASING OR TUBING(gesetfier all closed-oep)
2.Well Construction Permit y LAD FROM I To DIAMETER I THICKNESS I MATERIAL
Ccunn,Stutv. ;uriuntv c•tej ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Weil; i7.4WREEN
FROM To DIAMETER SLOTsIZE THICKNESS MATERIAL
DAgricultural Municipal'Public ft ft. in
:3(5i'othevinal(I fcating.'Cooding Supply) Residential Water Supply(single)
Iniustrial/Commercial Residential Water Supply(sliared)
18.GROUT
-1(rr'liggation FROM I To MATMU EMPLACEMENT METHOD&AMoVNT_
Non-Water Supply Well: ft ft.
:)Ni.ritorm­ DRecovcry ft. ft.
Injection Well: ft. ft.
—lAquifer Recharge OGroundwaieT Reinediation
Aciui fer Stoulge and Reco%ear OSalinity Barrier 19.SAND1GXAV.EL.P.A.0 (11'stavikable)
FROM TO EMPLACEMENTMEIHOD
Aquifer Test DStorrnwatcr Drainac ft.
Experiowntal Technology [)Subsidence Control —+ft, ft.
r-I(jeothertnal(Closed Loop) OlTracer 20.DRILLING LOG-tattach additional sheeh it necessary)
rlGeothermal(14eatinelCooling Return) E)Other(explain under;�21 Remark') FROM DESCRIPTION(rotor.h.rdnC4Son,'rvck typt.?"i"size,etc.)
ft. ft. r 4
4.Date Well(s) ID# it.
Sa Well Location- ft. rt.
ft. ft.
r tt �d
Foc`ifiry.'(;wner Nanie Facility ID--I If applicable) ft. ft.
ft. ft.
Phy,ical Addrels.'City.and Zip I ft. ft.
21.REMARKS
VX
County Parcel Identificatioo No,(PINi
5b.,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one laulong is sufficient) 22.Certi oD
N W
6.Is(are)the well(s)o Permanent or E)Temporary _Xgliaturc of'Cenificd Wcll Contrawk6t DaIc
Br tqznmg ihisjo,­• I henhY cetiA-that The.urlko ,a., —crej rmumfrlc�in acedance
7.Es this a repair to an existing well: [IN-'es Q.) 'No !!i1h 15.4 A C,_4C 02C.011)0 , 15AAC4C 02C.0200 9-,11 Cun,,rrucri.n Standord�: id Y)".)
II this isorepair. ni All kno%n well rnnsicrinn itifiwinaun",k1plainthcnati,colibe
23.Site diagram or additional well details:
S.Hor Geoprobe!DPI'or Closed-Loop Geothermal Wells ha,ing the same You may use the back of this page lo pro%ide additional well site details or sell
con istnwti.on,only I 6W-l'is needed. Indicate l'01 NUMBER
'AL NUconstructionf wells construction details. You may also attach additional pages ifnecessary.
drilled:
'6. �11 SUBMI'l-FAL INSTRUCTIONS
9.Total stell dep1e_b*ooA land surface: M-) 214a. For All Wells: Submit this form within 330 days of completion of hell
ali depthsit'difterew i,trainph-i,'J'O(Yapid construction to the following:
40
10.Static water level below top of casing: (ft.) Division of Water Resources,sources.Information Processing Unit,
11,voter lr,elix abv,caring.use— 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6118
124b. For Wieciion Wells: III 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 fitioNxifie:
(re.-auger,rotary,cable.direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16-16 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_� Method of test: Air Flow 24c. For Water Supply&Infection Wells: In addition to sending the fonn to
Chlor Tabs /2 Lbs the addresses) above, also submit bmit one copy of this form within 30 days of
Ob.Disinfection type: Amount: completion of well construction t!o tile eottnty health department of the county
where con;tructcd.
Form GW-I North Carolina Department of Em-irumnenzal Quahiv-Division of Water Rzsoiirccs Revised 2-22-2016