GW1-2021-05488_Well Construction - GW1_20211013

T
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
Robert Teague N%ATERS
TO DESCRIPTFON
1VeR Contractor Name COX,
-� \ �B & K Well Drilling IncQX ^��15`(�yNG iormutttca4ed:rvetl5 ORLINERi ii'e licabkT
G D41N[F.TER THICKNESS MATERlAt.
2857-A (�� ��� ft. 614 1" SDR-21 PVC
C ornpany Nanic 'IJp��N� 16.INNER CASING OR TUBING WelbermOf Closed-loop)
tV`r /�� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: y LS tt tt in.
I.is!ull applii ah/e I+'edl con.rrnurriun p<•+'+n!15 li.c.Z IC.C ow,nt Stwe.VariwlCC.err.)
3.Well Use(check well use):
17..S` tEEN
Water Supply Well: FROM TO DIAMETER N4LOTSIZE THICKNESS MATERIAL
Asricultural municipal:Public rt- ft. in.
.Geothumal(heating,Cooling Supply) Residential Water Supply(sing°lc) ft• ft. in.
Ind ustriaUComnlercial 'Residential Water Supph(shared) 18.GROUT
Irrigation
FROM TO MATERLAL EMPLACEMENT NIETHUD K.4MOLR4T
f[. tt. ,
Nun-Water Supply Well:
hlonitonnu, DRecov°ery ft. ft.
injection Well: ft. ft.
aquifer Recharge []Groundwater RemediatioD 19,SANDtGR4VEL PACK(if a licabte)
lAquifer Storage anti Reco\'ery Salinity Barrier FROM TO MAT ERLAL EMPLACEMENT METHOD
r'lAquifer-fest [3Stonnwaicr Drainage k. ft.
Experimental Technology DSubsidence Control
Geothermal(Closed loop) D Tracer 20i DRILLING LOG(attach additional sheets jUnecessa
FROM TO DESCRIPTION colon hardness.soWrocktt e. min sizc.ctc.l
RGeothermal(Heating/(:ooling Return) Other(explain under 421 Remark,) ft ft. `
ft. ft. L
4.Date Well(s)Completed: 7 ' Well ID# -
ft. ft.
5a.Well Location:
ft. u.
�rl.►� i l l cS I l (i A t Y t[. ft.
Faciliry'itcanerN;�P_ VL, 6,
Facility ID idapplicable)
\ �3�'` �`3 , d ft.
Physical Address.City.and Zip
21.RE NL•1Rlf$
County Parccl idenlilicalion No.IPINt
5b.Latitude and longitudc in degrees/minutes/secunds or decimal degrees:
(ifwell field,one laulong is sufficient) 22.Certl �� J
N W ji��Z►Y�
tgnuturcofCcmficdWei ontracIwr Datu
6.:Is(are)the well(s) x Permanent or Temporary'
. Br steninC this/ix-in.1 herehr crrliti'rear the nzlh.<I tvac!x•crc)enucrn+erect in atcnrdanie
7•Is this a repair to an existing well: 13Yes or No irli SA�C.tC 02C.0100 a IJA'At.IC 02C.02fi0 It'e17 C unsn'ur"iiwr Standards and rhut n
r
IfYhis is a repair,fill n,«knoc+n will tna<uvetinn inlonnarinn a .rpinin nc�na«uY o1 nc�
corn'of 11; rerard ha hecr,prn vided to the a ell owner-
,ep,tir under:,N rrnrark.,sir rion w'm the huek of this form. 23.Site diagram or additional well details:
You ma�'use the back of this page to pro%ide additional well site details or vicll
S.nstr Genpro only
I G or is n ed ed. I Geothermal Wells hat iR_the same construction details. \`ou niay'also attach iddiiioiial pages if necessary.
constmction,only 1 GW=1 is needed. Indicate'COT.ALNUViBERofwells
drilled: — r� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_dam! (ft-) 24a. For All Welts: Submit this form within 30 days of completion of iscll
For muhiple +r/!t Gsr all deprhi it diflFrrn!rermnpf+•-S: 'QO'mid';'n;l(i0 I constriction to the following:
10.Stafic water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
11+rarer Ir+zl it ahm e .,.d«g.use 1617 Mail Service Center,Raleigh,NC 27699-1617
1'I.Borehole diameter: 6 1/8 (in.) 24b. For Injection Wells: to addition to sendin,the form to the address in 14a
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 i.e.auger.rotary.cable.direct push,etc.i
Division of Wafer Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: air Flow 24c. For Water Supply&lliection Wells: In addition to sending the fonn to
13a.Yield(gpm) the address(es) aboA e, also submit one copy of this tonn within 30 days of
Chlor Tabs Amount: 1 v2 Lbs colnpletiou of well construction to the colmty health department of the county
13b.Disinfection type: whcr'c constructed.
i
I
Font C;R'-I North Carolina I)epanment of Envirunntenral Qualify-Division of Rater Rzsi`urces
Revised_•2'_-2t116