GW1-2021-05422_Well Construction - GW1_20211013

W'ELL CONSTRUCTION RECORD(GW-1) For Internal al Use Only: .............
L Well Contractor Information:
Robert Teague r.S 0 il-V 14.WATER ZONr—rs
Well Contractor Name FROM TO F_DF_scRrpT1oN
B & K Well Drilling Inc f e>S fr. ft.
NC Well(ontractor Certification Nimbei
15.OUTER licable
2857-A FROM PT.2 DLIMETER THICh1vESS NLATERIAL
Company Namc 0 " I I' a - I gI- ! ka' SDR-21 PVC
16.INNER CASING OR TUBING(Iteether 21 Cl&6&l00DI
2.Well Construction Permit#C)=�� �-1 o TO —DIAMETER THICKNESS MATERIAL
1.4f all applicubli:,sell eonstnutian pe"nils lix.UIC(.'olotri..Stale.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
A. E
FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
DAgricultural E)Municipal/Public ft. --ft. in.
:)Gcollicn-nal(licating/Cooling Supply) DWReiideniial Water Supply(sinvlc)
ft.
Lndustrial/Corrimercial []Residential Water Supply
(shared) I 1.1GROUT
Irrigation FROM To NfATEJZLkL F.11,11PLACENIENT METHOD&..AMOL.T.K.T
Non-Water Supply Well: ft. ft.
[IMonitoring ORccovcr} ft. ft.
I Injection Well:
Aquifer Recharge ®Groundwater Reinedia(ion ft.
LI
19.9ANDiGR-AVEL PACK fif applicablel
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERL4L EMPLACEMENT RIETHOD
Aquifer Test [3Stonnwater Drainage ft.
Experimental Technology [3Subsidence Control ft. ft.
n-Ueotlierrnal(Closed Loop) JD Tracer 24.DRILLINGLOG Nftiih addRional.shiftts ifineceisshry)%
0
FROM TO DESCRIPTION(color.hardn",t.sollfrocktilx.gmin We,c1c)�peotherrnal(HeatinglCooling Return) Other(explain under.4*21 Remarks) ) . '�
* 1 r 1 D_
4.Date Well(s)CompletedAq 3 Well ID#
5a.Well Location:
1-1 us-, ft.
fL
Facility,10wrier Name Facility ID=(if applicable) fr. ft.
7_2 S ft.
Physical Address.City.auT:25p ft.
21.REINI.ARKS
(3y)
County I Parcel identification No.(PIN I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laVlong is sufficient) 22.Certifica
-W
6.Is(are)the well(s)OPermartent or [DTemporary- SIgiiuturL-ofC'+crtificd Wcll Contras Date
Bi signing this Corot.I herch'y cen.iti that the iir/l(s)ivem turre)ennsinicied it?accordance7.Is this a repair to an existing well: 13Yes or L frith �IACIC 02C.0140w,15.6C,IC 02C.0200 0'ell Cunsiritudun Siandardsand that,,
If this is a repair,ill out kno-i Nell consuca irnit inibrina,init Nd,"plain the nature ql'the copy of this reenrd has hcen provided to the urli oiciter.
repair under#21 rentai-A.,xvchon at on the back of this'.form. 23.Site diagram or additional well details:
S.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of this page io pro ide additional well site details or tell
construction,only I CTW-I is needed. Indicate TOTAL NUMBER ofwells construction details. N'ou may also attach additional page-,ifnecessary.
drifted: SUBNIII-I"AL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple constniction to the following:
10.Static water level below top of casing:40 Division of Water Resources.Information Processing Unit,
Il voter level is above raving.use'*+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i- 61/8 1
11.Borehole diameter. (n.) 24b. For infection Wells: in addition to sending the form to the address in 24a
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 push.etc.)
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&Infection i
� i Wells. hi addition to-ending the form to
the address(es) above, also submit lone copy of this fonn within 10 days of
13b.Disinfection type: Chlor Tabs Amount. 1 1/2 Lbs completion of well consn-ucti.on to the
ucted, county I I icalth department of the county
wherc constr
Form GW-I 8 North Carolina Department of Environmental Quality-Division of Water Resources I Re,ised 2-2-1-2016