GW1-2021-05490_Well Construction - GW1_20211013

FELL CONSTRUCTION RECORD - For Internal use Only-:
y r.'
1.Well Contractor Information: I
Robert Teague �(��,� t .w YE
arERzos ON
� FROM TO DESCRIPTION
Well Contractor Name '( r•\nJv`1� O ft. /' ft.
B &K Well Drilling Inc ' (6
r.0e",� L ft.
k"r �G�tO
NC tVell Contractor Cerliflcation Number �'��� �Q�N� ' 15.OUTER CAS[, G foe:5i as Jivells$?R LI?1FER iE: livable
FROM 70 DGMETER THICKNESS M_TERIAL
2857-A \ D ft. 6' 'Z ft. b 118 In' SDR-21 PVC
Company Nano 16.1 ER CASING iffir%(gee at
FROM TO DIAMETEMATERIAL
2,Well Construction Permit#: ft• ft.
List all applicable rrri/consrna:rion per,nits(i.e.U1('.Cowin%Stale,Vanmtce,etc)
ft. ft.3.Well Use(check well use): 77>SCREET
ater Supply W ell: FROM TO DIAnIETERNESS MATERIAL
Agricultural []MumicipaUPublic ft R. in.
Gcothentlal(Ficating%COuling Supply) Ksidcritial
sidential Water Supply(single) ft. ft. in.
Industrial Commercial Water Supply(shared) 48':GROUT >
FROM TO �L1TI:RL4L. EM1ipt.ACEMENT A(ET'HUD -:AMOUNT
Irrigation ft. ft-
Nun-Water Supply Well:
Monitoring DRewcen• rt• ft'
injection Well: n, ft.
Aquifer Recharge ®groundwater Remediation 19.SAND)GR4V1sL:PACK if a ticnbtel
Aquifer Storage and Recovery E3Saliniry Barrier FRohl To
nIATERLAL EMPLACEMENTMETHOD
ft, ft.
r3Aquifcr Test [3Stormwatcr Drainage
Experimental Technology Subsidence Control ft. ft.
(n-othermal(Closed Loop) Tracer 20 DRILLING LOG(attach additional sheets if:neema
ry
FROM TO DESCRIPTION col ,hardness soutrock a c. rain sue-etc)
Geothermal(Heating/CoolingRetum) Other(es lain under..421 Remarks) fL r ft. ' I
4.Date Well(s)Completed.
ID
Well ID# ��s ft. Inc
ft. ft.
5a.Well Location: ft ft
f[. f[.
FaciliryfOwner Name facility nt'applicable)
ppN
J ajn
ft.
Physical Address.City,and Zip
21.REAIARICS
County J� Parcel identification No.I PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell field,one lat'lonc is sufficient) 22. emit atio
r
iiaturc of Cenified ell Contrr r Detc
6.Ware)the well(s) permanent or OTemptirary
Sr signing this forut.1 here)m certdi•that the xrll(s)rv& t>,•ere)cnnsintrted in accordance
7.Is this a repair to an existing well: QY'es or I drh 1 s e n('.IC 02C.olt)I)ur 15A NCAC 02C.0200 well Cansrruction Standards and that a
lfthis is a trpair.fill otn knoM+r n•cll consinecitnn injnnnminn at d tsplain the nano,nfthc
copy of this reenrd has peen prnvided to the xrll orm•r.
repair tinder,Zl rrrnerki srctiun OF on tyre iutt"k ofthis f.rm. 23.Site diagram or additional well details:
You may use the back of this page to pro%ide additional well site details or�kell
$.For Geopro or Closed-Loop Geothermal Wells haying the same constnlction details. You may also attach additional pages if necessary.
construction,onllyy I G�-l is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMI"1-1 AL INSTRUCTIONS
9.Total well depth elow land surface: (ft) 2�a. For All Wells: Submit this form within 30 days of completion of well
Fnr natltiple liar all depths ifdj/fcrent n:rnmpte-=ia'OII and 2pal00•) construction to the following:
10.Static water level below tap of casing:40 (ft.) Division of Water Resources.Information Processing Unit,
11 curer tic is water
le casing. w o " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (inJ 24b.For infection Wells: in addition to sending the form to the address in 124a
Air Rotary above.also submit one copy of this fom)within 30 days of completion of well
12.Well construction method: constntcdon to the following:
(i.e.auger•rotary.cable,direct push,etc.)
Division of Wafer Resources;underground injection Control Program,
1636 Mail Service�Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
f : Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the torn to
73a.Yield(gpm) Method o test the address(es) above, also submit one copy of this torn within 30 days of
Chlor Tabs /2 Lbs completion of well consiructioril to due county health departinetrt of the county
13b.Disinfection type: Amount:
where consnnctcd.
Form GW-I North Carolina Department of Emironnrental Quality-Division of Water Resou�es
Rc,'iDepartment22-016