GW1-2022-01837_Well Construction - GW1_20220216

................................
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague 19ATERZONES :
FROM TO DESCRIPTION
Well Contractor Name `+ �aA
B& K Well Drilling Inc FEB 16 2-����- ft- c.�
NC Well Contractor Certification Number _ 1OU fE1tCINC ft.
t�,r>,�e: nI@Itt'cssea: lls::orz:;r;31�'s.
2857-A t�P Cam " FROM To DIAMETER THLCh1VE6S MATERIAL
"f '` I
0 ,5 6 t/8 ' in. SDR-21 PVC
I
Company Name -
b::73si1'S&. ''SINCs�t'FifBtDEG: eefLetm�:ctosed-t0+i ;
2.Well Construction Permit# U= / FROM I TO I DIAMETER I THICKNESS I MATERIAL
AL
all applicable well construction permits(i.e.UIC.Caunrv,Stare. Variance,ear.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMtmicipal/Public ft. fa in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Residential Water SuRpplyIndustnaUCommerual shared _.
(shared) s< <>X. >iss:::>.<»;....
lrri ation FROM I TO NLATERLI L EMPLACEMENT METHOD&AMOLINT
Nun-Water Supply Well: ft. it.
Monitoring 13Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge nGroundwater Remediation
19i`5ALVfNGRAyF.L#'AGtC 6f livable _ ;
Aquifer Storage and Recovery DSaliniry Barrier FROM TO MATERIAL 1 EMPLACEMEYT METHOD
Aquifer Test OStormwatcr Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 28::DR1LLING:L0G:attachaddiLiii atsheets:T'
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM o- DESCRIPTION color.hs as sotVrockri ram size,etc)
( d ft. f /.S ft. rA
4.Date Well(s)Completed:i)-4 7 l Well ID# i s ft' G ft'
5 Well Location:
ru�� L tL ft.
Facilwner Name Facility 1D#(if applicable) ft. ft.
ity/O
3 Ica I Le 1� 1/aI ft. ft.
Physical Address,City,and Zip ft. ft.
2I REiCIpFRKSi
County Parcel ldentific�ition No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifiea on•
N W
6.Is(are)the well(s)opermanent or Temporary Si_ t us f Cc cd Wcll tr KtLiV Datc
By signing this form.1 herel!v certify that the xrlits)was!were)coauntcued in accordance
7.Is this a repair to an existing well: [3Yes or No pith 1S4 NCAC 02C.0100 or 114 NCAC 02C.0200 Well Construction Standards and that itIf this is a repair,ill out knokm well construction information and lain the nature of the cope of this record has been provided to the xrll owner.
repair under#21 remarks section or on the bark of thio:fonn.
23.Site diagram or additional well details:
8.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,onl 1 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple+ve/ls list all depths ifdii ferew(erainple-3@200'and 3 tt)001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
If water furl is above casing,use-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For iniection 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: construcuon to the following:
(i.e.auger,rotary,cable,direct push.ac.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
P
13b.Disinfection type:
Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form G%V-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-'_016
II