GW1-2021-05492_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague 14,WATER ZONES
q FROM TO DE.SCRrPTiON
Well Contractor Name 021 ) s�ft. ft,
B& K Well Drilling Inc 1 2 ( l
(l�. V��t jZ5 ft• 270 ft. l ��
NC Well Contractor Cenificacian Number �Ce Je�g1C\�J 15.OUTER CASING(for' lirca4ed tretls E?R'LtNEii`if kea(rle.<l:
2857-A 1��1(;e3r�5�,(,ZOn FROM ft TO tt DG�MF-TER-1 TMCKNFSS MATERIAL
r� p o t18 SDR-21 PVC
Company Namc [� 1 16.INNER CASING'OR TUBING eetbeimat closed toe
2,Well Construction Permit# 1_7 `I�-G 1 FROM TO DIAMETER THICKNESS M ITERIAL
list udl applicable well consinictiun.Permits li.c.WC C OW11Y,Stara,Variance,ett.t R. ft. in.
ft. ft. in.
3.Well Use(check well use):
17iSCREEN
Water Supply Well: FROM To DIAMETER L SLOT SIZE THICKNESS MATERIAL
Agricultural E)Mu nicipaL,Public ft ft, in.
Geothermal(licating/Cooling Supply) WResidcricial Water Supply(single) ft•
industrial/Commercial Residential Water Supply'(shared) a$i GROUT
_ .
Irrloe[iDn FROM I TO MATERL4L EMPLACEMENT METHOD B.4MOQNT
Non-Water Supply Well:
Monitorin_ E]RecovM, ft. ft.
injection Well: ft. ft.
Aquifer Recharge ®groundwater Remediation
19.SANDIGRAVEL>.P-kc (if a liceDle
QAquiferStotlige and Recovery IDSalinity BarrierFROnI TO RIATEPL-L EMPLACEME`1TIHETHOD
pAquifcr Test [3StoiTnwatcr Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20,DRiLL1NGL0G(attaehaddstiendflibeetsifeieelI
iFRo
OMM T DESCRIPTION color, rdness.solLrockn , msnc Mel
al(1leating/C OOlin Return) Other(es lain under#21 Remark,) ftDate Well(s)Completed: --3 V Well ID# . tt-
5a.Well Location:
ft.
Facility7OwnerNam�eA Facility tDy=(ifapplicable)
�•�\\�G�r '��s 1y� Qf \ ft. ft.
ft. ft.
Physical Address.City,and Zip
r 21.REniARKS
County `J1 Parcel lde.ntif3ea*ion Na IPIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certifl¢atfo
N \\
StettaturcufCcrtifred Weil Comr• for Datc
6.ls(are)the well(s)OPermanent or E)Temperary
Br signDrg this/orrn.1 herein:crrtili-that the xrlll.<1 wnc/K•crc)ennvnterrd in aeenrdvnce
7.Is this a repair to an existing well: Yes or No ,ith l:.l\('.IC 02C.ol,)r),,r 15.4 NC.4C i)2C.0200 Nell Consrrut:rioii Sr(indtirds and thin a
!f this is a repair.fill oil'kno-tt Well can.sinnrinn injnnnaiinn an explain the nature n(thc copy o0his record has been prnvided to the urll ormer.
repair under r21 rtmark.>suction or on the hark of this.h,rnt.. 23.Site diagram or additional well details-
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pro%ide additional well site details or well
construction,only I GW- is needed. Indicate TOTAL NUMBER�of wells construction details. You may also'attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple ur/k lift all deprhs if different taratnple-3,(i::'00'and--'@,100') construction to the following:
10.Static water level below top of casing:40 Division of Water Resources.Information Processing Unit,
11 Nater level is above Casing.rase"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Tniection Wells: in addition to sending the form to the address in 21a
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 pus1L eta)
Division of Water Resources,underground Trajection 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: Irr addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlor.Tabs t 1/2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type: Amount: P
where constructed.
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Fonn UTA'-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201 o