GW1-2021-00176_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD(GW-1) For Internal use Only:
1.Well Contractor Information:
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Robert Teague
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FROM TO DESCRTPTTON
Well Contractor Name
B&K Well Drilling Inc ��t '
NC Well Contractor Certification Number °`tcilFE1t:GAS1fvG cssed`'
2857-A FROM TO DIAMETER THICKNESS MATERIAL
0 ft. (, ft. 61/6 SOR-21 PVC
Company Name
_ G 1 :1L� B G YSIAG 4Ef FiJHve
2.Well Construction Permit#• 15 �� —/ FROM TO DIAMETER THICKNESS MATERIAL
list all applicable well consimcrion permits(ze.UiC,Corarty,Stare,Variance,etc.) t[. ft. in.
3.Well Use(check well use): ft. ft. in.
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Water Supply Well: .....................:._................PPY FROM TO DIAMETER I SWTSIZE THICKNESS MATERIAL
Agricultural Municipa Public ft tt. in.
Gcothennal(Heating/Cooling Supply) Rcsidcnnal Water Supply(single) ft.
Ind ustn'aUCommerc ial CSidenual Water Supp
ly(shared)
lrri atiOn FROM TO NLATERLAL ENn LACEMENT NEETHOD&AMOUNT
Non-Water Supply Well: rt. tt.
Monitoring ®Recovery
injection Well:
_'Aquifer Recharge C)Groundwater Remediation
.d9iS61V#)YGR�V�t,l`4CffGi fife
Aquifer Stor2ge and Recovery []Salinity Barrier FROM TO 11LATERM Eld ACEME.NT;L—
nAquifer Test [3Stormwatcr Drainage ft. ft.
Experimental Technology Subsidence Control ft. fL
NGeothermal(Closed Loop) Tracer 2&:DRII LII!ra 6 :' tta ;add;ttoislc+i# :'
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM n. TO ft. DESCRIP ION(color.ha m sollfrock in size,eta
4.Date Well(s)Completed: Well ID# t' 51- t
Well Location: CD OS fc.
0tM5e\ TV UY J>CA 0 rNCA
Facility/Owner Nante Facility IDg(Applicable) ft. ft.
6 Ca
ft. ft. 1
Physical Address City,and Zip
RE1lFAR1
�CA.k C �r.l Its' It ^ y� t•
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifte
N W
6.ls(are)the well(s)oPermanent or Temporary Si aturc of certified Well Gm or Date
By signing this(ornr,1 hereby certffy that the well(s)war(were)comirucred in accordance
7.is this a repair to an existing well; DYes or V D Frith 1 SA NCAC 02C.0100 err 1 SA NCAC 02C.0200 Well Cunstruction Standards and that a
IJ this is a repair,ill out knoKm well construction infonnadon and explain the nature o(the copy o(this mcnrd ha been provided to the xrl(owner.
repair undt-r 921 remarks section or on the back of ihis.furtn. 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 details. You may also attach additional pages if necessary.
construction,only.11 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: JI SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of.completion of well
Fnr mulriple nrl/t lift all depths ifdiiferent(ararnple-3r:200'and 2@100� constniction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
!)'water level it above casing,ute-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For infection Wells:; In addition to sending the form to the address in 243
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 kVELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of rest: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Ghlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
Where consouctcd.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016
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