GW1-2021-05491_Well Construction - GW1_20211013

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Wt'LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14,WATER ZONF-1;
Well Contractor Name
FROM TO DESCRIPTION
a5-5ft. ft.
B & K Well Drilling Inc 6a M
ft. (LI 7V
NC Well Contractor Certification Number f1 Cj 1 15.OUTER CASING 06r: 4fi-cased. Is),
?K
2857-Aess ,RON TO DLAMETEi T1 N111
Wirerft. ft, lit.
..loin
Company Nano 01 SDR-21 PVC
10 16.INNER C J 'BiNG(keetbermall cloii&f0ep)
2.Well Construction Permit#: L) c`cl FROM TO DIAMETER THICKNESS MATERIAL
List all applicable vvll eonsmiedwi permits Ii.e-UIC.Coulin.Slut'?.Variu;;Ce,et".) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.'SCREEW-
FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public IL ft.
:)Geothermal(11cafing/Cooling Supply) DResidential Water Supply(Single)
ft. ft. in.
Dindustrial/Commercial I&CROUT
[)Residential Water Supply(shared)
Irrigation FROM TO MATERIAL FM.PLACUMENT METHOD&AMUUTT
Non-Water Supply Well: ft. ft.
7)Monitoring DRecovery ft. R.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Reinediation 11,SAND/GRAVEL It
Aquifer STorlge and Recovery [3Salinity Barrier FROM TO MATERLAL EMPL CEMENTMETHOD
Aquifer Test DStormwatcr Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 211.-DRILLING10G eittaiih addMenil sheets:i[jiecessRary). ......
( n . W.g .
Geothermal(Heating/Cooling Peturn) rJOther(explain under#21 Remarks) FRON[ TO DESCRIPTION coi/,hardness soillrockt� nin size etc)C�) ft-
3 n_
4.Date Well(s)Completed:�) Well ID# C', ft, ft. zr-) t( /(Z- If k�0 ri
Well Location:
Facility/Owner Name facility ID-* 'a livable) ft. ft.
(A L k 'X'n eof 1p, ft. ft.
Physical Address.City,and Zip ft. ft.
21.REALARKS
County Parcel Idel)1ific4,6o,,No.(PlNi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field•one laulong k sufficient) 22.Certification-
W, 1'_2
Ci-
6.ls(a'r*e)the welt($)0 Permanent or [3Temporan Si-nature ofCcrlificd WaKoniTdctor Dat.
Br signing thisjorm.I heirbY certiA that the mr1k.0 iva%turre)continued in accordance
7.Is this a repair to an existing well: !R"Vesn.,or 1�o
Il this is a repair.fill ina blOM77 Nell connnecii. I;", in" Tplain the notta-c ropy ofthis reem-d has heen pr-vided to the rll mozer
repair iwd,,s-;J21 remark-5 section urvii the hat-kofthisfurin. 1. 23.Site diagram or additional well details:
S.For Geoprobe,'DPT or Closed-Loop Geothermal Wells havin,,the same You may use the back of this page'to pro%ide additional Nell site details in:Tellconstiniction,only I GW-I is needed. Indicate TOTAL NUMBER of wells constniction details. N'ou may also attach additional pages if necessary.
drilled: 4 SUBMITTAL INSTRUCTIONS
9.Total well depth belo-A land surface. (ft-) 24a. For All Wells: Submit this,form within 30 days of completion of well
construction to the following.
10.Static water level below top of casing:40 (ft.) Division of Water Resources.Information Processing Unit,
If iwrei-lean/is ahot-e casing,use'+ ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8
.(in.) 24b. For infection Wells. In audition to-nding the form to the address in
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.auger,rotary,cable,direct pusli.etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C!enter,Raleigh.NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 74c.For Water Supply&Infection Wells: In addition to sending the fonn to
the addTess(es) above, also submit one copy of this forrit within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction ttJ the county health department of the county
where construLted.
Form Cyr'-I Nonh Carolina Depanmeni of Environmental Quality-Division of Water Resources Revised 2.22-2016