GW1-2021-05421_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: C
Robert Teague �- M WATERZONES
Well Contractor Name
FROM To DESCRIPTION
B& K Well Drilling Inc c1 j 2021 ft. 16 5
ft.
NC\Fell('ontractorCeniticationNumber `��,.4,� t 15.OUTER CASIs G foi`mawtased:We1ls:ORLIW-11 if. ieable':
FR
2857-A �yifi�tl �vJ>I�cj?' �� U DI TO DIAMETER M THICKNESS 4IERIAL
Company Name
p ft. fr- 61/8 I in. SDR-21 PVC
e� a 7�l 2 16,INNER CASING OR TUBING eelibermaf cldsea-Joe
2.Well Construction Permit"#• FROM I TO DIAMETER THICKNESS MATERIAL
lar all applicable well construction permits d.e.171C.Cotnmt Stute. Variance,etc.) ft. I ft. in.
3.Well Use(check well use): ft. ft. in.
::17:SCREET.
Water Supply Well: -
FROM TU DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipalTublic ft ft. in.
Geothermal(Hcating/Cooling Supply) MResiderEial Water Supply(single) tt. tt in.
Blnd ustrialiCommercia l Residential Water Supply(shared)
A84 GROUT
Irrigation FROM TO MATERLAL EMPLACEMENT NfETHOD&AMOI'NT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery
injection Well:
ft. ft.
7JAquifer Recharge ®Groundwater Remediation
19i SAND/GRAY EL'PACK a 7icablel
PAquiferSTordge and Reco%"ery [3SalinityBarrier FROM TO MATERLAI, EMPLACEMENT METHOD
Aquifer Test E)Stolmwatcr Drainal_c ft, ft.
Experimental Technology Subsidence Control ft. ft
(ioothermal(Closed Loop) DTracer 20.DRILLING:LOG'Yattachaddltienelsheety:iLnecesss .
Geothermal(Heating/Cooling Return) 00ther(explain under.21 Remarks) FRONI TO U&SCRIPTION color,hardn . soltrock tspc.emin size.eta)
ft. ft. C
4.Date Well(s)Completed: " ti� �� Well iD# ft, ft*
C� - 1
5a.Well Location: 1 t. ft. Q klej
K real d r� Zr�n� CLrd too r-e< S
Fa,ilityipw4er Name facility ID=(if applicable) fr. ft.
v; zn L a ft. ft
Physical Ad6css.City,and Zip ft. ft.
t�i �r✓d l n�Q r �� t t�2 U 21.REMARKS
County Parcel Identification No.(PINI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sumcisrlo ""ti :
W -
6.ls(are)the well(s) Ix Permanent or E)Temparar Datc
g� Br signing this loan. 1 herehr eertifi-that the nrlhs)swcs fume)comintered in accordance
7.Is this a repair to an existing well: I__f Yes or 1n +:ith 15,4 ACiC 02C'.0140 or 114 NG{C 02C.0200 Dell Cunstructiun Standards and thou u
lfthm is a repair,ell nur kno%,n well ennsintctinn injormafinnAd(,. lain the nature ofihs, copy of this rt'cnrd ha.s heen provided to the cell o1oler.
repair under:21 remurkc srcrion or on tla-hark of this form.
23.Site diagram or additional well details:
8.For Geoprobe,DPT or Closed-Loop Geothermal Wells hating the same You map use the back of this page to provide additional well site details or well
construction,only 1 G -I 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: S S (ft.> 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr nwhiple nr/Is li.,t a//depths if dil(erent teramph+-3.'i!'NJ'and_'(-a';1 fff) construction to the following:
10.Static water level belowtop of casing:40 (ft.) Division of Water Resources.Information Processing Unit,
Ihvater level is above arcing.use— 1617 Mail Service Center Raleigh,NC 27699-1617
11.Borehole diameter 6 118 (in.) 24b.For infection Wells: in addition to sending the form to the address in 34a
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 puslL 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) I I Method of test: Air Flow 24c.For Water Supply&Infection Wells: Iii addition to sending the fonn to
the address(es) above, also submit one copy of this fonn within 30 days of
Chloe Tabs 1 vz tbs completion of well construction to the corm health department of the count
13b.Disinfection type: Amount: 1 n' eP' Y
where constructed.
I
Form OW-1 North Carolina Department of finvironmental Quality-Division of Water Resources' Revised 2-22-2010