GW1-2021-00111_Well Construction - GW1_20211109

LL CONSTRUCTION RECORD
GA-I For internal Use Only:
i,Well Contractor Information: R`:7;oNiS:: cRrnTTON Y
FROM TO
Robert Teague 9 D-Ll «.
Well Contractor Narne �S ft. a ft. .l J t i>3ia8i
B &K Well Drilling Inc ''Fi#sFfstt'Cii511G< ": s MArErttAL
D
t�ctavEs TO
NC Wellell Contractor Certification Number FROM tit '� tt 6 118 in, PV SDR 21 C
cl 3b8
2857-A 1 <jBG:E11?' !!1� THICKNESS MATERIAL
7 FROM TO DIAMETER
Company Namc it in.
it.
2.Well Construction Permit#: ft. in.
T.ut all aPP
r Fell construction permits(i c.U1(',Comrrv,State.Variance,etc.) ft.
: FROM ft.
DIANIL'rER SLOT SIZE
��THICKNESS����MATERIAL
3,Well Use(check well use)
-
ft
ft. in.
Water Supply WeIl:
Lic
�MtmicipaUPub tt. '
Agricultural Rc�Idcn
tial WateT Supply(single) ft
Gcothcrtnal(Hcating/Couling Supply) esidential Water Supply(shared) ITN tETHOD&ANrnv{
FROM TO NtA1'FRLtI.
ladustriaUCommercial tit it
ini atiun ft.
Nun-Water Supply Well: ft.
�. Recocery tit.
Monitoring
injection Well: EMPLACENIEVT NI"HOD
C)GroundwaterRemediation > SgN#NGl? vt '�iCtC: f
FROM TO NLATERLAL
Aquifer Recharge oSalinily Barrier ft.
Aquifer Storage and Recovery [3 ft.Stormwatcr Drainage tit ft.
Aquifer Tcst
Subsidence Control
tiacJsadrti9ori'ii1 R: m size,etc
Experimental Technology 2&<AR1iuf11`l o
Tracer FltONt DESCRIPTION rotor,hs s.soiVnxl:
Geothermal(Closed Loop) 0
(ex lain under#21 Remarks) ft, it.
Geothermal(Heatin Coolipn Return)
��- it. it.
4.Date Wells)Completed:(��s—)Well iD# ft. ft. l
ft. tt.
52.Well Location: ( z tit.
r \
Cl l 01^',c I ft.
Facility 1D#(ifapplicable)
1 ft. ft. �..
.fiFacility/Owner Name i3 _
Physical Address,City.
/fand Zip �ILi:F� •
Parcel ldentificationNo.(PtN) I I
County
.r
Sb.Latitude and longitude in degreeshninutes/seconds or decimal degrees: 22 Certif
(if well field,one lat/long is sufficient) W / )
Date
N
r�taturo of Ccnificd We untraetur
6.is(are)the well(s)OPermanent or Temporary ei. igning this form.1 hereby certify that the xcH 0 w ll(were)ction Scted r acca'dance
',ith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 well Cunsrruct un Standards and rhnr«
Yes or No copy of this•record har been provided to the Kell oivner
13
7.Is this a repair to an existing well: 2t
Ifthb is a repair,till out brown Kell cnnsiructiat infannati«n d rplain the mauve of the 23.Site diagram or additional well details:
You may use the back of this'page to provide additional well site details or well
repair under#2l remurfa section or on the back of rhis furrn.
construction details. You may also attach additional pages if necessary.
C W 1 is needed. Indicate TOTAL N UMBER of wells
S.For Geoprobe/DPT or Closed-Loop Geothermal('✓ells having a same
constnrction,on 1 ly SUBhi1TTALiNSTRUCTIONS
drilled: / If/1 S within 30 days of completiou of well
lJ (fL) 24a. For A� II Wells: Submit this form
9,Total well depth below land surface: constntction to the toll°"mom',
For multiple ur.ILc lit all depths i(different(eratnpl4eo3/a'-'00'and?@100') (tit) Division of Water,Resources,information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
c form to the
th
11'warer level is a/+ in 243
ore casing,use +
6 1/8 24b.For ini�lion Wells: inoadhis n to form within 0 daysf couplet onsOf well
11.Borehole diameter:
(In.) above,also submit one copy
12.Well construction method:
Air Rotary construction to the following:
(i.e.auger,rotary.cable.direct Push etc') Division of Water Resources,Underground injection Control rogram,
1636 Mail Service Center,Raleigh,NC 27699-1636
the form to
FOR WATER SiJPPL LLS ONLY: of this form Nvithm 30 days of
It Method of test: Air Flow 24c.For Water Su i & this wells: In addition to sending
the addresses) above, also submit one copy health department of the county'
13a.Yield(gym) t i/2 Lbs completion of well construction to the °°anti}'
Chlor Tabs Amount: where consnucted.
13b.Disinfection type:_--- — Revised'-22 2016
North Carolina Department of Environmental Quality-Division of Water Resources
Form GW-1