GW1-2021-00047_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
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Robert Teague
FROM TO DESCRIPTION
Well Contractor Name
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B &K Well Drilling Inc 9 ft.
NC Well Contractor Certification Number - rlta#trcii4ed. -
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2857-A FROM TO DIAMETER THICKNESS I MATERIAL
Company Namc
0 ft- L ft. 61/8 SDR-21 PVC
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2.Well Construction Permit#: r FROM TO I DIAMETER LTHICKNESSI MATERIAL
List all applicable well construction permits ii.e.UIC..Cowin•State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): fc. rc. in.
Water Supply Well: _._ SCi;R_._....._....._......iA.........R -SIZ....... . .....
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FROM TO DIAIIILTER SWTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. 11 in.
Geothermal(Hcating/Cooling Supply) Rosidenual Water Supply(single) IL fL in.
Ind ustrial/Commercial 'ffesidential Water Supply Shared
PP- (Shared)
Irrigation FROM To NUTERLAL EM:PLACEMFNT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery
Injection Well.
ft ft.
Aquifer Recharge OCroundwater Remediation
19i:SeY1V#)/G1>9k :#!4f'ff{if.
Aquifer Stor2ge and Recovery E]Saliniry Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwatcr Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 24:DRTLEIlv4iLOss itRchaddiiiorie}s '''`:`"'
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRIPTION Color.ha css,soil/rock °ruin size,etc.)ft. j.,, ft.
i.
4.Date Well(s)Completed: c 1, Wel1 ID# L tt. rc.
5a.Well Location: '' �� tt. ft.
-ACJLI k I�LL_��l 1 1 � • ft. ft.
FFaaccUiity/Owner Name FacihEy lD,�(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft. N O v 92021
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County Parcel identification No.(?TN) ECTION -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 04FORMATION PROCESS 1 t
(if well field,one lat/long is sufficient) 22.Cer on:
N W —
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6.Is(are)the well(s)oPermanent or OTemporary Sipaturc of Certified Well Co; for Date
Bs signing this form,1 hereby certify that the well(,)was(x•cre)constructed in accordance
7.is this a repair to an existing well- Yes or No n ith 15A NCAC 02C.0100 or I SA NCAC 02C.0200 well Construction Standards and that o
If this is a repair,ill our known well construction infiannation an explain the nature of the copy o(this record has been provided to the well owner.
repair under 921 rent-Az.sectiun or on the buck of this.funn.
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 provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages if necessary. a
drilled: SUBMITTAL INSTRUCTIONS'
9,Total well depth below land surface: ^;C (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wM/A 11st all dep//u if different(erainple.3r200'and 3 a,1001 constnuction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
(f water level is above casino,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ In.
(� ) 24b.For Tniection 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
Flow
13a.Yield(gpm)� Method of test: Air 24c.For Water Sunply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chloe Tabs Amount 1 vz tbs completion of well construction to the county health department of the county
where consauctcd.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 2.22-2016