GW1-2022-01835_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Is-.r Robert Teague
FROM TO DESCAIPTTON
Well Contractor Name n ?.5 C ft.
FEB162Z ?
B&K Well Drilling Inc 2�Sri 27 rt
NC Well Contractor Certification Number ��F f7c:yc�..mo UNA 15zOTi 1Eit CAS1tvrG AVElls'E3Ri l�A tt
2857-A VI14UE .r �f3 FROM To DIAMETER 7ffiCIQVESS MATERLAL
0 ft. ft- 61/8 SDR-21 PVC
Company Name
16::1f�?98RfS1I�1GfiflR Fl)BilitG McMaCtitised 309
,ALL? FRONT TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ((// TT C7 fL ft. in.
List all applicable Well cotlstruction permits(i.e.UIC•,County,State.Variaice,etc.)
ft. ft
3.Well Use(check well use):
L7:Sl3tEEN...;: .. .
f
Supply Well: FROM TU DIANIL'TER CWTSIZE THICKNESS MATERIAL
cultural 13Municipal/Public ft
hermal(Heating/Cooling Supply) Residential Water Supply(single) tt1 sl
rare
dsmaUCortrmercral Resldenual Water S PP Y( ) aBstDi3€ _,.............._:.............::.......,.........
FROM TO NLITERLAL EMPLACEMENT NMTHOD&.AMOUNT
lrriaatiun ft. ft
Nun-Water Supply Well:
Monitoring Recovery ft. ft.
injection Well: ft. ft.
Recharge g:.)Aquifer a C3Groundwater Remediation
1'J SAi\iNGitAvE1 PAf C Gf heable
Aquifer Stor9ge and Recovery E)Saliniry Barrier FROM TO NI.ATERLAL EMPLACEMENT METHOD
Aquifer Test 13Stormwatcr Drainage ft. ft.
Experimental Technology oSubsidence Control 2A.TIItITL1NG1.00itnachaddrR
ft tt.
Geothermal(Closed Loop) Tracer
_.' 'r1fo91s1Deet3:Rasee3a '
FROM TO DESCRIPTION color hard LSOMMck-type, min Ametc.)
Geothermal(Heatin Coolie Return) ,Other(ex lain under#21 Remarks) ft. / ft. ;;,.k C ,
4.Date Well(s)Completed:l-l� Well ID# C � tt `�P✓�- ft
ft. ft.
5a.Well Location:
ft. - ft.
Facility/Owner Name Facility Wit(if applicable)
ft. ft.
ft. ft.
Physical Address,City.and Zip
1�C_- 2I';RE14fPi1ZliS _.... .
Parcel identific:nion No.(PTN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: �p
N W
SiEztatun:of certified Well Cuntrec r Date
6.ls(are)the well(s)OPermanent or Temporary
B'v signing this(orm.I herelm certify that the xrll(.$)was(were)constn(cted in accordance
7.1s this a repair to an existing well: Yes or E)No with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,ill our known well construct: 1 in rmotion and explain the nature of the copy of this record has been provided to the well owner.
I
repair under 921 remarks sectiun or on the bark of this furor. 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.
drilled: 71 SUBMITTAL INSTRUCTIONS
9.Total well depth.below land surfice: (ft) 24a. For All Wells: Submit j this form within 30 days of completion Of well
For multiple wells Iry all depths ifdifferent(example-3@ 200'and 2 r.1001 construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources.Information Processing Unit,
if water level is above casing,use••+ 1617 Mail Service Center,Raleigh,NC 27699-1617
r
11.Borehole diameter: 6 /8 (in,) 24b.For injection Wells: Inladdition to sending the form to the address in 34a
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,rosary.cable,direct path.etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Air Flow 24c.For Water Supply&Itiiection V►'ells: In addition to sending the form to
Method of test
13a.Yield(gpm) the address(es) above, also subunit one copy of this form mvithia 30 days of
136.Disinfection type Chlor Tabs 1 1l2 Lbs completion of well construction to the county'health department of the county
Amount
where constructed. i
Revised'_-22=016
Form CW-1 North Carolina Department of Environmental Quality-Division of Water Resources
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