GW1-2021-00174_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD(GW-1) For Internal use Only:
1.Well Contractor Information:
Robert Teague 14.WATERZON&S
Well Contractor Name FROM TO nF-I;CRTPTrON
B& K Well Drilling Inc �6 'C'btit �)
NC Well Contractor Certification Number G
15.OUTERCASIN kiiiiiiii I
2857-A FROM 1 TO DIAMEW�fmw"T�W[`:�:
0 ft. ft. 5 in. DR-21
Company Name I PVP
16:INNER CASING-OR 1-1'BING, eether 21 cl&e 000)
2.Well Construction Permit fE 111 )ILI I z FROM - TO I DIAMETER THICKNESS I MATERIAL
List all applicable w-ell consiniction permits(i.e.UIC.(:aunn-,Stove. VarianCe,el".1 fLJ ft. in.
3.Well Use(check well use): ft. tit. in.
W
41.SCREEN ater Supply Well:
FROM TO DIAMETER IZLOTSIZE THICKNESS MATERIAL
DAgricultural Municipal./Public ft ft. in.
:)Geothermal(I[eating/Cool ing Supply) Residential Water Supply(single) —ft. ft. in.
I Industrial/Commercial BResidendal Water Supply(shared) A.S.GROUT .. .1. .. .:..
� ...........
-1Irrigation FROM I TO NIATERLA L EMPLACEMENT N.fET.HOD A.M.OL,T.N.T
Non-Water Supply Well: ft.
71Monitoring EIRecovery
Injection Well.
ft. ft.
Aquifer Recharge ®Groundwater keinediation 15 SAND/GX4VELT9CK If iniblicsible)
Aquifer Storage and Recovery [3Salinity Barrier R .......FROM TO MATEPLAL EMPLA EMEYT I%IL"rHOD
PAquifer Test DStormwatcr Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
lGeothermal(Closed Loop) Tracer 20.DRILUNGCOG-Nittach addMonad:sheetsff omeim.ry)
Geothermal(Heating/Cooling Retum) 0Other(explain under 421 Remarks) I FROM TO DESCRIPTION; (color,hardness S9n'rocktW.gnin SJ?.c,cTcJ
4.Date wells)CompleteA-:5 Well ID# ft. ft.
5a Well Location: ft.
ft. 3 7071
S ca.0�4 4—
FacilityiOwner Name Facility 11)z iifapplicable) ft. ft.
SOL, V� ft. ft. wrt'p,SEC I I&!!_ rl I
Physical Address.City,and Zip ft. ft.
21.REALkRYS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(il'well field,one laulong is sufficient) 22.Certi
W
6.ls(are)the well(s)opermanent or E)Temptirary Snrnuture ofCcnificd Well C;)O .ctor Dal
h�y ssigning this forn n,:ceri.iA-that the%rlk�)vmv turre)cowinicred in accordance
7.Is this a repair to an existing well: [)'V'es or No
is 4 rhi.i a repair,till ow known well ennstruciinn injorynatinn V n-explain the nature qfihe copy ofihis rcenid has been provided in the Nrfl corner.I
repair i(ndri-1121 remarks srction or on the back(it thisfurni. 23.Site diagram or additional well details:
8.For Geoprobe.'DFT or Closed-Loop Geothermal Wells hating the same YOU may use the back of this page io provide additional well site details or hell
constniction details. N'ou may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: I
4 SUBM11"I'AL INSTRUCTIONS
.To
tal t
al well depth below land surface: (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of Nv,;Il
Fn,-multiple well;lim all delvitis ifdiflervnt terainple-3,11-700'and 2(ji100') construction to the folloNvin.:
10.Static water level below 40 top of (ft.) Di-vision of Water Resources.Information Processing Unit.
J/water Imeli.,above casing.fue'*+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Air Rotary above.also submit tine copy of this forivi within 30 days of completion of well
12.Well construction method:
construction to die following:
(i.e.auger,rotary.cable,direct pushetc,)
Division of water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) \,-96 Method of test: Air Flow 24c.For Water Suonly&Iniectio in Wells: In addition to sendinz the form to
Chloe Tabs 12 Lbs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to Ithe county health departnient of the county
where constructed.
Form OW-I North Carolina Department of Em i runmental Quali i y-Division of Water Resources Revised 2-22-2016