GW1-2021-06290_Well Construction - GW1_20210915

1
WELL CONSTRUCTION RECORD (GW-1) V Or lot-m-I Use Only:
1.Well Contractor Information: Qt�
Robert Teague ,� �+� WWAXERZONE SS
l� DF.SCR TION
WellCbnfractorName lev C^� � rt,B& K Well Drilling Inc Q e�; rt.NC'tell Contractor f ertifiC,160 Number � G�' vG toe ma1Li- esad-welts OR LINER'ita IieableltJ� t-\� DIAMETER THICI:NESS MATERIAL
2857-A r ��' p ft. rt 5 t/a 1° SDR-21 PVC
`
Company Mane 16:INNER CASING OR TUBING Weet8ermaf closed-loo
FROM70 DIAMETER THICKNESS M.ATERtAL
2.Well Construction Permit k: , l�I` ft it- in.
I.i.sr:dl'apphcahlc++ell oonsymcriatr pcvrnirs Ii.e.l'1C'.Counn..State. Variance.eri l
ft. ft. in.
3.Well Use(check well use):
11 SCREEN '
Water Supply Well: FRo._i TU DIAnI ETER SLUT SIZE THI('KNESS MATERIAL
Agricultural [3MunicipalrPublic ft. it. in:
Gcothcnnal(Hcaling:Cooling Supply) Rcsidcmial Water Supply(single) tL f[, in.
IndustriaUConintercial Residential Water Supple(shared) IS.GROUT i
FRU:•1 TO NIATERL4L EMPLACEMENT-METHOD d'•AMOUNT
Irrigation tt. ft.
Nun-Water Supply Well:
hfonitoring EIRecoN cryft. ft.
injection Well: ft. ft.
Aquifer Recharge C)Ciroundwater Remediation
lY:SAIvDlGRA�EL PACK if applicable)
BAquifer Storage and Recos ery [3Salinity Barrier FROM TO MATERIAL EhfPLACEME.NT AIETHOD
ft. ft.
Aquifer Test DStonnwatcr Drainasc
DIGsperimental Technology Subsidence Control h, ft.
Cjerother nal(Closed Loop) 1 Fracer 20;DRILLING LOG(attach addttionel:sheets:if necessary -'
FROM TO DESCRIPTION color.hardness,Will km e. rain size,ttcl
Geothermal(Heat inelCooline Return) Other(ez lain Linder Q21 Remarks) ft tt. 40
ft. 7 iQ ft.
4.Date Well(s)Complete 2, Well ID#
59.Well Location:
ft. ft.
rt.
Facility/Owner Namc Facility ID=(Ifapplicable)
rt.
ft. ft.
A-k.\\ c,i l7e r,ve ✓ ft. rt.
Physical Address.City.and Zip - -
3b9�f/ O I d 761 Q} 2I.REMARKS
Colinty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(If'a'ell field,one laclong issufficieni) 22.Certification:
N - 1 a- 2)
Sit:nature ufCertificd Well ContraLtn Date
6.Is(are)the wells)j Permanent or [3Temptn-ary
Br signing chic%non,.I herchr ecrrih"-lira;the roll./.V+vro (urre)cnil nicred in accordance
7.Is this a repair to an existing well: Yes or �No „'ilh,'3.4�C.tC 02C'.01d0 ur 1 iA tiCAC'02C.0200 IrcN Cunsiruotia„Standards antd thw
If thi.+is a repair.ill ow knonn aril comuved , arnmtion and cgliain the natw a n.ffhc
rnpy of thi.t recnrd hai peen provided in di,arl!o+nter.
repair undo-=21 rr,narAi si-rtnm ur.m der hnc.4 0!r cis Juan' 23.Site diagram or additional well details:
You may LISc the back of this page to prm ide additional well site details or +ell
S.For Geoprobe!DPT or Closed-Loop Geothermal Wells hat ing the same construction detail;. You stay also anach additional pages if necessary.
constniction,only I GW-I is needed. Indicate TOTAL N U MBER of wells
drilled: T
/�,1 C Sl1BivI1TAl.INSTRUCTIONS
9.Total well dep t below land surface: �y J (ft-) 24a. For All Wells: Submit this fonn within 30 days of completion of well
rnr nnthihle n•e/l.c li+tall drpdrs i(diflirent rernnq,l<•-;f�2 100 and Z(a,Hit)') constniction to the followin^:
40
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
" 1617 Mail Service Center,Raleigh,NC 27699-1617
II'n'u lee let'el is ahr-v Casing.tote
Borehole diameter 6 1/8 (in.) 24b.For lniection Wells: in audition to Sending the fonn to the address in 24a
above. alsu submit one copy ofGthis form'within 30 days of completion of well
Air Rotary
12.Well construction method: constniction to the following:
(i.e.auger,rotary.cable.direct push,ere.)
Division of Water Resources,underground injection Control Program,
FOR WATER SUPPi.,Y WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: Air Flow 2�1c. For Water Supply&Injection Wells: hi addition to sending the fonn to
13a..Yield(gpm) the address(es) above, also submit one copy of this fonn within 30 days of
Chlor Tabs Amount- t 1/2 Lbs complction of well construction to the cotuity health department of the county
I3b.Disinfection hype: where constructed.
Noah Carolina Depan v
inem of Enironmen,al Qtialiiy-Division of"ater Resources Revised '-'--2016
Fnnn GV,�-1 k
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