GW1-2021-00188_Well Construction - GW1_20211213

For lnterTial Use Only:
WELL CONSTRUCTION RECORD(GW-ll JI
1.Well Contractor Information:
14,WATER Z.OI!fES DESCRIPT(O
Robert Teague FROM TO
ft. rt.
well Contractor Name 0
B&K Well Drilling Inc ft. ft. '
OUTERCASING ►� 01FLINER'if. MATERIAL
NC well Contractor Certification Number FRONI TO DIAMETER TffiCKNESS
2857-A 0 tt. ft• 6118 in- SDR-21 PVC
14.INNER EASING OlI'LiJ$tN11 >mstd
Company Namc OUMETER THICKNESS M.aTER1AL
7 q FROM TO
2.Well Construction Permit#:
}/l 1t. f[. in.
List till applicable will construction permits(i.e.Lt(C',Cotorrv,State,Variance,etc.) ft. ft. in.
3,Well Use(check well use): _17,SMIKENi
FROM TO DIAMETER St.OTSIZE THICKNESS MATERIAL
Water Supply Well: ft. ft. in.
Agricultural �MtmicipaUPublic
) �Rcsidcntial Water Supply(single) ft- rt.
in.
Gcothcnnal(Hcating/Cooling Supply
InduStrial/COrnmercial Residential Water Supply(shared) .I&GROUT NIATERL�I. EMPLACEMENT Nt>iTHOD a.1Mo[?r'r
FROM TO
Irri ation ft. ft.
Nuti-Water Supply Well: ft. ft.
®Recovery
Monitoring
n. ft-
injection Well: licaWt)
Aquifer Recharge �C;roundwater Kemediation 19.SANiNG1LAYEL t'AGK EMPLACEMENT NIET
ry° HOD
NIATERL',1.
Aquifer Storage and Recove 3Saliniry Barrier FROM TO ft
� ft.
Aquifer Test Stormwater Drainage
Subsidence Control ft. ft.
Experimental Technology 28_DRILLING:LOG:stack agditioital sleet+R eecess
Geothermal(Closed Loop) Tracer FROM TO OESCRI TIO.N color-hardness,solUrock is •Drain size,etc)
Other(ex lain under#21 Remarks) 0 ft. ri� (t. l; � V r—
Geothetma](Heatin Coolie Retunt) lJ "1
4,Date W"ell(s)Completed 1 well ID# /
art. rt. 'NI x
52.Well Location: ft. ft. " 0 7
is
f
FNanle Facility ID,'(if applicable)
t. ft.
acuity/owner
` JJ ft. ft.
ft. ft.
PEP
physicaall Address,City,and Zip 2I ftFiCraRtte
Parcel identification No.(PIN)
County
Sb.Latitude and longitude in degrees/minutesisecunds or decimal degrees: 22 Cerfifi o
(if well field•one lat/long is sufficient)
N W (Date
SrpreturcufCettiftcd Wcll vntractnr
6.Is(are)the well(S)opermanent or [3"Iempnrary gv.vignirte rh;c form.1 herelry certify,that the well(s)'H'ar/were)cnnuntandcied in accordance
that
with 15A ACAC 01C.0100 or I:A:NCdC 01C.0100 Well Construction SutnJtrrJs and thm u
7.Is this a repair to an existing well: 13Yes nr Lam''fain the na[tve oI t/re cops•p/this reccrd has hcen provided to the xcll ouncr.
ll o+tt known well cnnstructiot+infonnatinn d p
(frhLs is a rcpab',f 23.Site diagram or additional well details:
elwir undo s11 remarks section or on r/tr hark pf this(ern+. you may use the back of this page to provide additional well site details or well
S.For Geoprobe/DP?or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. indicate TOTAL NUMBER of wells ¢UBn11TTAL IN TRU IONS
drilled:
—(ft-) 24a. For All Wells: Submit this form within 30 days of completiou of well
9,Total well de th below land surface:_T construction to the following
Fornwlt;ple ur/ls lint all depths it dilferem iaranplc-3r2_t10'and'a!0!1') ri
10.Static water level below top of casing: (ft.)(ft.) Division of Water Resources,information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
(1,rater level it above casing,nee..
(in.) 24b.For iniection Wells: in addition to sending the form to the address Ill'Sa
6 1/8
]1.Borehole diameter: above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
Air Rotary constnicuon to the following:
(i.e.auger,[Dory.cable-direct pvah,etc.) Division of Water Resources,Underground injection Control Program.
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
3 Method of test: Air Flow 24c.For Water SuuDly&Infection Wells- I11 addition[o sendin;the days
to
13s.Yield(gpm) the address(es) above, also submit one copy of this form tof'ttred?ountY
Ghlor Tabs Antaunt
1 1/2 Lbs completion of well con.,tructiou to the county health department
13b.Disinfection type: — where constructed.
Revised 2-2'201 o
North Carolina Department of Environmental Quality-Division of Water Resources
Form Cw-I