GW1-2022-01839_Well Construction - GW1_20220216

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WELL CONSTRUCTION RECORD(GW-11 For internal Use Only:
1.Well Contractor Information: -ED DEaCRfPTt
s^, �� t4 WATER ZUNES
Robert Teague t, ,Ron, TO O"
Well Contractor Name � � 6 ft. T Q tt• ,� i
B & K Well Drilling Inc 6 zon b t eft
NC Nell ContractorCen DLIMETER THICKNESS M
ifica[ionNumber a` 1.r�fD,�j li fj U1li� 1COli EK'CtiS1NG a[nitt c rrelh'ORLilit t[
If riott1 FROM TO AIER,AL
2857-A [y��t�lc�+� D ft. tc• ava 1II SDR-21 PVC
Company Name 7'bNERGI G.Oit Ft78fNC eethertlza.cl foe
•� � FROOM N TO DIAMETER THICKNESS MATERIAL
2.Wel!Construction Permit N: ft ft. in.
List all applicable well consrrucrion permits(i.e.U1C'.Corot,.State.Variance,etc.) ft• ft. in.
3.Well Use(check well use): t1,:SGREEN
FROM TO DIAnI ETER WT CIZE THICKNESS MATERIAL
Water Supply Well: ft N
ft. in.
Agricultural MunicipaUPublic
Gohthermal(Rcating/Cooling Supply)
VcnidLial Water Supply(single) ft tt m
_
idential Water Supply(shared) ;is.cROU
.Industrial/Commercial FROM TO ... rLA7'EgygL EMPLACEMENT METHOD&AMOLINT
Irrigation ft. ft.
Nun-Water Supply Well: h ft.
Monitoring [3Recovery
ff ft
injection Wen:
Aquifer Recharge E)CiroundwaterRemediation 19:5AND/GR4Y-EL:t'siCiCfif liciblel
FROM TO pI ATERLAL EMPLACEMENT b1ETHOD
Aquifer Storage and Recovery E)Storro Barrier FROM
ft.
Aquifer Test �Sotmwatcr Drainasc
Experimental Technology Subsidence Control
�- 29>DRIIIING'LtIG attathaddrEtbne#sheetsi[:ueeess
Geothermal(Closed Loop) E 1Tracer FROM TO DESCRIPTION rntor,hardnec olVrocAn ram size,etc)
gg'
Geothermal(Healing/Cooling Return) Other(explain under ft21 Remarks)
ft. eft. t 0
L rL o ft. 0%4-3 V e.
4.Date Well(S)Completed: Well ID#
� rt. ft.
Sa.Well Location: f. ft
� ft ft.
Facili /Ownzr Name Facifty tDit(if applicable)
ft. ft.
Physical Address,City,and Zip 21
C r RF1trAI KC
iN.t 4 �—
Parcel identifirttion No.1PIN)
County
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Corti lion: _
(if will field,one[at/long is sufficient)
N W G$�ntatun:of Certified Well Co actor Date
6.is(are)the well(s) Permaneot or Temporary
BY signing C.4 /ono.1 6erehv certify that the [)we,11 Construction Si ndardsand accordance
Frith 1.fA NCAC 02C.0100 or l?.4:NCAC 02C.0200
7.Is this a repair to an existing well: Wes or No cap ofthis record has Fecn provided to the well o urge.
If this is a repair,ell our known well construclio 7*nnation and explain nce nature oft/c
repair under�Zl remarks section a'on the hark o(thisloran• 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
6.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER ofwells SUBNI1TTA1.INSTRUCTIONS
drilled:
9.Total well depth below land surface: (ft-) 242. For AU Wells: Submit this form within 30 days of completion of well
Far multiple+trllc ICcr al[depths i(dijferent t::rample-3t�c-'dt1'and?`na,1011')
construction to the following:
40 (ft) Division of Water Resources.Information Processing Unit,
10.'Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
iJ'unter level ie above casing,uae-+
6 118 (in.) 24b.For infection Wells: Inladdition to sending the ton
m to the address in 3la
71,.Borehole diameter: above. also submit one copy of this form within 30 days of completion of well
12.Well construction method:
Air Rotary construction to the following:
I i.z auger,rotary,cable,direct push etc.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: to
Method of tesr Air Flow 24c.For Water SuuDly&Infection Wells: In addition to-ending the form of
13 .Yield(gpm the address(es) above, also submt one copy of this form within 30 days of
t 1 1/2 Lbs completion of well construction to the county health department of the county
Chlor Tabs Amount-
13b.Disinfection type:�— where consnUctcd. i
Reoised 2-22-2016
North Carolina Department of Emironmental Quality-Division of Water Resources
Form GW-1