GW1-2021-08133_Well Construction - GW1_20211109

CORD GW"� For interrial Use Only-
WELL CONSTRUCTION RE �---� 1
1,Well Contractor wormatioD: uEscRlPTtoN'
pROAI TO
Robert Teague
Well Contractor Name ft.
B &K Well Drilling Inc ;..:s'�ieEtttAstr? ;iveigcss nLaTERInf
PRON1 TO r SOR-21 PVC
NC Nell Contractor CeDIA
rtification Num tt ft. 5118
u
2857-A E3RtZ f MATERIAL
`C�7 ��y(/r� DIAMETER THICKNESS
�/ �-�- FROM TO in.
Company Name (t,
f[.
2.Well Construction Permit#: in•
u:ell cons muction permit OX,UI( C",V.State.Varimtce,etc.)
?5iii::<i;S:ci?>i ;i! )3 i :i;»:2Jjy}<:%>i'o1;
List all applicableMATERIAL
`.• . ' tAh1EfER St„OT SIZE THICKNESS
3.Well Use(check well use): 1; M To ft. 1n.
Water Supply Well: ft
unicipaUPL, is it.
p
le) ft
Agricultural udcnttalWater Supply(sing
otTNT
Geothermal(Hcating/CoolingSirpply) R idential Water Supply(shared)
industrial/Commercial Commercial u. To ft.
irrigation ft. ft.
Nun-Water Supply Well:
Recovery ft. ft. ;
Monitoring
elite: ST METHOD .
injection Well. Groundwater RemediationSg;+tf?/GiY9vLi q EMPLAceME
>LATERL4L
Aquifer Recharge FROM iO it
Saliniry Barrier it.
Aquifer Storsge and Recovery �[3Stormwatcr Drainage ft.
ft
Aquifer Test Subsidence Control atiachaddinotis#s> taro srzc,ctal
:,2$:�ov'-VING0� �. DCRIPTION color,hardncs soiUrock
Experiment alTechnologyTracer FROM To ES
Geothermal(Closed LOOP) ft.
Conlin Return) Other(ex,lain under#21 Remarks) ft.
Geothermal(Heatin ft. t.
yt�..� _ �WelliD# ft. t
4.Date Well(s)Completed:�—�—
ft. t
5a.Well Location: �> t9 ft.
ft.
Facility ID#(if applicable) ft. ft.
Facility/Owner Nante ft
physi
cal Address,City,and Zip
Parcel identification No.(PIN) ,r
County +
Sb.Latitude and longitude in degrees/minutes/seconds or decimaldegrees: 22.Certifica
(if well field,one lat/long is sufficient) W
Datu
N Sitatatun;of CcnificJ We l COntro Cit
6.is(are)the wells) Permanent or E3Temporary Well Cunstructiun Standards and that a
By signing th (onn,I hereby certify that the well(S)was lw•crc)can rn+cred in actor ante
pith 15A NCAC 01C.0100 ur 15A;NCAC 02C.0100
7.►s this a repair to an existing well:
Dyes or No copy of this record has been provided to the xrll owner.
23.Site diagram or additional well details:
Ij this is a repair.. out known well construction infannatiar n rplain nc�nature o(t e
You may use the back of this page to Provide additional well site details or well
repair under#21 remt+rks sectiun ur on the hack ojthis funn es if neeessaty.
p thermal Wells having the same constriction details. You may.also attach additional pages
S.For GeoprobelDPT or Closed-Lon Geothermal SUgnft f t AL INSTRUCTIONS
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells within 30 days of completion of welt
drilled: ��� (ft.) 24a. E0_ AIW lla: Submit this form
9.Total ivell depth below land surface:
construction to the following:'
Far nrulriple nellc Iry all deptIL,ifdifferem(etratnpl�o3ra;--0 and l'@I00� (ft) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is al'ove Casinguse %$ 24b,For Tor iecti�"Wells° In addition to sending the form to the address f ell
11.Borehole diameter:
V (1°) above,also submit one copy of this form within 30 days of completion of well
Air Rotary construction to the following?
12.Well construction method: Division of Water Resources,Underground h°NC 27699-1 36 ction Control Program?
(i.e.auger,rotary,cable.direct push.etc.)
1636 D1ai1 Service Center,Ra g
FOR WATER SUYpt•Y WELLS ONLY: s of
Air Flow 24c.For Wa�rabove,alsoilsubiriit�dneelcoP of thisofortnSv�thin 30c days to
Method of test: the address(es) health department of the courtly13a.Yield(gprn) 1 1/2 Lbs completion of well consmti tton to the count}'
Chlor Tabs Amount: where consouccctl.
13b.Disinfection type:�--- Revised _22?Ot o
FEnvironmental Quality-Division of Water R sources
North Carolina Deparnnent o
Form OW 1
i