GW1-2021-06332_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD{GW-1) For lnlernal Use Only:
1,Well Contractor Information:
Robert Teague la.WATER ZONES
FROM TO DFSCRIPTiON
Well Contractor Name i j ft. H-7)ft. / r
B&K Well Drilling Inc t/� r
NC W01 Contractorr Ce,lification Number 15.OLTER CASING for tetittii''cased::sreth OR LINC1t<if 8 lieable <:
2857-A FROa£ TO DLIPIETER THICt:NESS 'ATERMAL
0 ft. ft. 6 t/8 ta. SDR-2t PVC
Company Name l6.INNER` A5INGORTUBING iotbertnalclosed-loo
L 1
2.Well Construction permit#:(�, rV ! r FROM TO D1AMET€R THICKNESS M.aTEaIAL
List d/applicabic*call ctmsrmenon permits fix,UIC.Coann..Soar.-,variwme,ere.rin-
3.Well Use(check well use): n. fc. in.
Water Supply Weli: 1,7.S(_MEEr
FRONT TO DIAMETER `;F.OT tiIZE THK`.KNE$S ?NATF.RIAt.
Aericulturai C),lunicipal Public tt- rt. in.
Gcothcrna!{Hcating'Cooling Supply) Residential Water Supply(stnlc) ft. !'t. in.
IndustrialiCornmercial Residential Water Supply(shared) 15:GROUT
irrioalion FROM I To NIATERRI. EMPfACEMENTpf£THOD&.IMOLWr
Non-Water Supply Well: ft. ft.
hlonitorimg Recovcry ft, ft.
Injection Well:
fi_ fL
aquifer Recharge ®Groundwater Remediation
19.SAND)GR.AVEL PACK(it a .lleable
:Aquifer Storilge and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:]Aqu l`cr Test [3Stotmwatcr Drainage ft. ft.
DExperimental Technology Subsidence Control tt. ft.
:1,Cicothermal(Closed Loop) DIracer 2o:DRILLING-LOG(suschaddittenal::sbeexv:i£necessary
Geothermal(HeatinV(Iooling Retum) 0then(explain under 21 Remarks) FROM r4 DESCRIPTION color.hard .s soiFroct a c, ntln srrc cxc)
S'� <
4.Date V1 ell(s)Completebl - 1)-2-1 Well ID# it. ft. i
5a.Well Locatiio -
n: �1 v t l�l l l ✓ c (�
RA`o L 1 S ft. ft.
Facility%Owner lane Facility ID=(ifapplicable) ft, ft.
7 r 6 ,�^ i j 1+ �p .1
k r1! C�,1 1 (� L�V V����V�:� fL ft. f
Physical Addres.City.and Zip fr. ft. I
21.REAIARKS
Cowrty Parcel ldentific;+tion No.(PIN) —
5b.Laritude.and longitude in degrees/minutes/seconds or decimal degrees:
(if utll field,one,lat'lony is sufficient) 22.Certirp tlo' DWR Section
6.1s(are)the well(s) Permanent or �Tempnrar} SrenaturcofCenificdWell ractor Date
$r siCnhge this lorra.I herch-It ccrtftr that the xrWO was tt<•erc)rnnunicred or accordance
7.Is this a repair to an existing well: IDYes or }No h i3.9 C.iC 02C.r)!00.n I,i,A CdC 02C.0100 n'rll t un-arrur:riun Sunrdrrrds and rh<a u
Ifrhrs is a repair,fill ow kuo%v rr0 conximoin»ialbnnarimr and e.plain the nautre nfnc� �7?t'of this record hoc heertlxnvidcd to the xr11 oirrcer.
repair toile'#21 renrar-ks secriutr ur wir the h<rx'k ufdn.,juror.
23.Site diagram or additional well details:
S.For Geoprobe;DPT or Closed-Loop Geothermal Wells hat in^the same You mad ltse the back of this page to pro%ide additional well site details or t ell
constriction,only I GW-I is needed. Indicate TOTAL N UMBER�of wells construct-on details. N'ou may also attach additional pages if necessary.
drilled: - SUBMITTAL INSTRUCTiONS
9.Total well depth belor land surface: �', QIi (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nt dripir+wftr liar al/depths it dijlcrrnr r,tramphl _i''r)9'and is?;ItNt't construction to the followinn:
I&Static water level below top of casing:4O (ft.) Division of W5tter Resources.Information Processing Unit.
ft twff:level is ahn,•r;asin=,r,w-+ 1617 Mail Service iCenter,Raleigh,NC 27699-1617
11.Borehole diameter. 6 118 {in,} 24b. For ittiectiaa Welts: in addition to sending the fonn to the address in?-ia
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.2uger,rotary,eahle-dircet push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16361tfail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _,• Method of test: Air Flow 34c. For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this ftxtn within 30 days of
Chlor Tabs t 1i2 Lbs completion of well construction'to the sotto health de nartmcnt of the count
136:Disinfectiontype: Amount: 1 ty 1' Y
where constructed.
Fonti GR'-i Non Carolina Depanment of Environmental Quality-Division of Water Resources Revised 2•22-2016
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