GW1-2021-00045_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Robert Teague iS.WATER ZONES
FRO>I TO DESCRrPTiO.
Well Contractor Name 3 S ft. ft.
B & K Well Drilling Inc t,. ft.
NC Well Connactor Certification Number 15.OUTER CASING far'tnulti•cased wells OR UNI lf'iLe IieableT>:
2857-A FRONT TO DL1hiETER THICKNESS MATERIAL
0 ft. ft. 51/8 in. SDR-21 PVC
w.
Compar y Nmnc ` 1b.1NNER CASING.UR TUBING eethermat rlosed-l000.
1� 1-- o► �s3
FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#:` ft.
ft. in.
l.i.st,dldpplicUN Nell Coll
r111lcrioli per+nitc/i.e.(11C.Cmmn..S'tale.Valiance.cll.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER 51.OT SIZE THICKNESS MAATCRIAL
Agricultural Municipal Public ft. ft. in.
Gco(hamal(Hcafing.Cooling Supply) Residential Water SUPPly'(single) ft. It. in.
lndustrial/Conintercial esidential Water Supply(shared) Ig.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOLiNT
Irrigation
ft. ft.
'ion-Water Supply Well:
Alonitoring ®RecoNcry ft.
injection Well: e. ft.
QAquifer Recharge ®Groundwater Remediation
19.S'.41ND!GR4VEL PACK if applicable)
Aquifer Su>t:Mge and Reco%'en DSalinity BB,TIer FROM TO MATERIAL EMPLACEMENT METHOD
�Aquifcr Test
DiStont%warcr Draina•_c ft. ft.
Experimental Technology DSLibsidence Control fr. ft.
Geothermal(('losedLoop) racer 20:DRILLING LOG(attach additiehal.sheeb'itneemary -
FROM TO DESCRIPTION r lor.ha ss-soil!rocktspe. in simcic.1
Geothermal(Heating Coaling Return) (Aher(explain under 21 Remarks) it ft.
tr
_?.1- tt• tt.
4.Date Wells)Completed: Well ID#(Q
ft. ft. O
5a.Ni'ell Location:
ft. R.
�v
h. ft.
�Faciifit�,,ltown Name Facility lDs(if applicable)
/ ft. ft.
fr. f[.
Physical Address.City.and Zip �+
' 21.RE9IARKS
Lilo• R sECTION
County Parcel denti(it:,non No.l PIN) It'FORMATION PROLE
5b.Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
(it vstll field.one I3L'10ng is sufficient) 22.Cel;tifi' �10�� ..
� . 7 -Z
Jr_natun•of Certified Wcll )ntractt)r Datc
Permanent nr 1•em
6.ls(are)thc.vell(s) x� orary P
Br signing%hie lam. 1 herein:c.'r/ifi'that the nr///.0+vaa(x'C+'c)rnaclntctrd in ai cnrdancr
` \n -ith;�4 A('.IC•02C'.0100 or 15.AC.('02C.0200 tv,-11 Cunsnu(iun Stemdards and that n
7.Isithis a repair to an existing well Wes or .Opy
I/tho*i.c a repair,fill(),ftkno%)?Nell rnnsmn ctin++ilUa-101i-1 a. r,lnin the natwa•ni 1h,
c n(this rerm•d l+as here provided to the xrll o-1wr.
iep„it..under t21 rvalark,w(tion or.at the hat:4,,1hi.,form. 23.Site diagram or additional well details:
Y'ou may use the back of this page to prmide additional well site details or cell
8.For Geoprobe!DPT or Closed-Loop Geothermal Wells has ing the same constntction detail;. You n,a)•also attach additional pages if necessary.
constntction,only 1 GW-I ii needed. Indicate TOTAL NUMBER�of wells
drilled: �- SUBMITTAL INSTRUCTIONS
9.TdlaI%sell depth beloe land sw face: (ft-) 24a. For All Wells: Submit This form within 30 days of compittiou of well
Fnr niultip(e+rell.c lint ar/depths i/diJlivrnt k;rmap!r-:_i:a10'gnd_'i[i)/flfl'1 conSlniction to the following:
lo.Static water level below top of casing:40 (ft.) Division of Water Resources.Information Processing Unit.
l(4'uler level i.c ahnve Casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) tab. For htiection 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%veil
12.Well construction method: construction to the following:
(i.e.auger.rotary.cable,direct push,etc.)
Division of Water Resources Underground injection Control Program.
FU(1 WATER SUPPLY WELLS ONLY': 1636 Mail Service'Center.Raleigh,NC 27699-1636
13a:Yield(gpm) Method of test: Air Flow 2.1c.For Water Supply&Infection Wells: In addition to sending the fonn to
the address(es) above, also submit one copy of this tort within 30 days of
Chlor Tabs Antount• t 112 Lbs completion of well construction to'the county health department of the county
13b.Disinfection type: whet,commucted.
Fonn GP'•1
North Carolina Depamnew of Environmental Quality-Division of Water Resources Revised'_•'-'_-'_Olo