GW1-2022-01836_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague F f
—��+ FRON K TO .. .. .DESCRIPTION
i S
Well Contractor Name ft. L\-10.
B&K Well Drilling Inc FEB 16 pz rt. rt.
NC Well Contractor Certification Number Urti1 IS:i)IiPEKCit1lYG. Iltitirasedi'velh fAls;ll12 fi:
2857-A I �' , FRONK TO DLANIETER THICKNESS M TERIAL
[jhyr � 0 ft. c ft. 6118 ID' SDR-21 PVC
Company Name I6.:(NSLEA4CA '.Gm.. eei�exm�t.cfoselkltie
2 FRONT TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: it. ft, in
List all applicable well construction permits(i.e. C',County,State.Variance,etc.)
ft. ft.
3.Well Use(check well use): -
WaterSupplyWell: FRonl TO DIAMETER SWTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft ft. in.
Geothermal(Hcating/Cooling Supply) csidcntial Water Supply(single) ft ft, in.
Ind ustrial/Commercial Residential Water Supply(shared) 11im,
FRONT TO NLATERLAL EMPLACEMENT METHOD&AMOUNT
lrri ation
ft. it.
Nun-Water Supply Well:
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
_.. Aquifer Recharge oGroundwater Remediation
19:�eYNtNGItAVE1,t'AClcflt We
Aquifer Storage and Recovery E)Salinity Barrier FRONT TO NLATERLAL EMPLACEMENT METHOD
�Stormwatcr Drainage ft. ft.
Aquifer Test
Experimental Technology Subsidence Control ft ft
Tracer 28;BRI3 LING.1 OG atlsi ti:additi6nal31rcets if u�eees9
Geothermal(Closed Loop) .,.)
FRONT TO ASCRIPTION color.ha es soiVrock is rain size,ete
Geothermal(Heatin Coolin Return) Other(explain under 921 Remarks) g � 5 t[. - a
4.Date Well(s)Completed: ;k a' It ID# ('' ft• b ft
ft. ft. 0.
5a.Well cation:
06
i�e,t� L Y tin
Fa flit ID#(ifa applicable) ft. ft.
/Facility/Owner name�/�/Q Y PP
1 C g V r r tL,., Y ��`/ale — ft.ft. ft.
Physical Address,City,and Zip f
C- �.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 24Certin:
N W ficd Wcll C tractor Date
6.1s(are)the well(s)SPermanent or [3Temporary
By signing this form.1 hereby certify that the xr11(s)was(n•crc)constrta:tcd in accordance
on existing well: E)Yes or o r11h 1 SA NCAC 02C.0100 or 1 iA NCAC 02C.0200 Well Construction Standards and that a
7.IS this a repair to
If this is a repair on.ill out known well construction information and ns ain the nature of dye copy of this record has provided to the xell owner.
been p
t
repair under 921 renua-Ad section or on the buck of this form. 23.Site diagram or additional well details:
S.For GeoprobelDl'T or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
I
construction details. You may also attach additional pages if necessary.
construction,only 1is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple urrlls list all depilts it dii ferent(arainple-3@g,200'and 2@100') 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
11.Borehole diameter: 6 1/8 (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to tine following: i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control,Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServicelCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also subinit one copy of this form within 30 days of
Chlor Tabs Amount: 1 112 Lbs completion of well constructionito the county health department of the county
13b.Disinfection type: where consauctcd.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016