GW1-2021-06291_Well Construction - GW1_20210915

.WELL CONSTRUCTION RECORD GW- For Internal Use Only:
I.well Contractor information:
Robert Teague ��� ''� 14,WATER ZOINES
� a FROM TO DESCRIPTION
Well Contractor Name ev\� eft.
B &K Well Drilling Inc C-0 o�` J�G p� ft. ft.
N( Well Conn'actor Cettiliwtion Number �r1� •�\� 15,OUTER CASING foriitolti-cased ivvelts)UR LINER<il'.b lieabk}
2857-A 4,vr�\ Q FROM TO DLIMETER THICKNESS MATERIAL
4
�� 0 ft. f[• o t!8 in. sDR-21 PVC
Company Namc �{ 16.INNER CASING OR T1!BING eotbermal doied•loo
t LI-59 JU FROM TO DIA-METER THICKNESS MATERIAL
2.Well Construction Permit tl: ft R. in.
l.rs:all uppiicuhk u•P!!r<»+snruaian permna t).c.l'!('.Caunn'.Stale Vuriunt i!.c•rr'1
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
\Vater Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS M.ATERIAt.
Agricultural [3Municipal Public ft. ft- in.
Gcothcnna!(Hcating.Cooling Supply') JKRcsi lential Water Supply(single) ft. fL in.
-IndustriaUComniercial DResidenlial Water Supply(shared) IS.GROUT
FROM TO NATERIAL EMPLACEMENT NIETHOD&AMOCrNT
Irrigation ft. ft.
Nun-Water Supply Well:
htoniturine ®Recovcry ft. ft.
injection Well: ft. ft.
aquifer Recharge ®Groundwater Remediation
19.SANlllGRayEL PACK if RVID12611blel
Aquifer$tut'dge and Recotery [DSaliniry Barrier FROM TO 9ATERIAL EMPLACVAENT METHOD
Aquifer Test DStonnwatei Drainage ft. fL
Experimental Technology 0SUbsidence Control ft. ft.
Geothermal(Closed Loop) 0\'racer 20:DRiLLING-LOG(attach additionatshmts if necessary
FROM TO DESCRIPTION color. er h cat soidreck n rain size,Mel
Geothermal(HeatintX:Ooling Retunt) Other(explain under 21 Remarks) ft. (t. `
ft. ft. �. Ae
4.Date Well(s)Completed: _L r)- Well ID# S Y
ft, ft.
5a.Well
Location:
M G L 1\� �1Y3J fL It.
rt. it.
�F,L,'l,'1q,'iOwner Nam• Facility ID=(ifapplicable)
ft. ft ft.
Physical Addreis.City.and Zip
` 21.REMARKS
County Parcel lJentific'r.tion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iru'cll tidd,one lao'long iS sufficienn 22.Certificatio
W
' Stgn: un a CumficJ Wd Contract Datc
6.Is(are)the well(s)O Permanent or [3Teirpm'ary
B, signing this%arras.1 herrhv ccniA.that the arllLrl wtn I..e,)cn,,n,ried in accordu+rcc
7.Is this a repair to an existing well: DVes or No
an tr?S.9>('.9<'02C'.!)!t)U or 1.i.4 C.aC J1C.(1200 tt'er!Cun,'rrucr;wr S+nnJrrrJx and rhur a
ennspvuunn f
cape al lhis rernrd hay been provided to the well o o r.
!(thu i.<a repair.fill gut knonn%.ell initirmauon .Tplaitt the nature n liri
rt p„ir❑nder=I1 rrnrurk>sr,-lion ur ur III,h,n'.4 of dri_<form. 23.Site diagram or additional well details:
6,For Geoprobe!DPT or Closed-Loop Geothermal Wells hat ine the same You may use the back of this page to pro%ide additional welt site details or wcrl
construction,only 1 GV-I io needed. Indicate TOTAL NUMBER of wells
construction details. !'ou may also attach additional pages if necessary.
drilled: SUBNIITIAL INSTRUCTIONS
9.Total well depth below land surface: `3 �3 (ftJ 24a. For All Wells: Submit this form within 30 days of completion of well
F.,mrr/riply�rrN.a tier atl depths i/d{flerrnr/.:rar»ple-S,_['t19'and_'(n';I rlD'I constniction to the following:
Io.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
it+rarer rrr'el is ahm-e casing.use"- 1617 Mail Service Center,Raleigh,NC 27699-1617
tl.Borehole diameter 6118 (in,) 21b.For Tniection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one cupy of1this form within 30 days of completion of well
12.Well construction method: constriction to the following:
(i.e.auger.rotary,cable,direct push,cw.)
Division of Water Resources.Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.'Yield(gpm) Method of test: Air Flow 24c-For Water Supply&Iniection Wells: In addition to sending the form to
the addresS(es) above, also submit one copy of this tbnn within 30 days of
Chlor Tabs Amount: t 1/2 Lbs completion of well construction to the county health department of the cotmty
13b;Disinfection type: where constructed.
Fonn C K'-1
North Carolina Depanmem of Encitonmental Qualit.-Division of Water Resources Revised'_-?_'-_01 o