GW1-2022-01840_Well Construction - GW1_20220216

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WELL CONSTRUCTION RECORD (GW-11 For lnterral Use Only:
1•Well Contractor Information:
y� L7-
�"< + % 14.WPi7'ER ZONES
Robert Teague FROM 70 DHSCREPTION
f,— I .
\Nell Contractor Name �a ft. / ft.
B&K Well Drilling Inc f t�3 1 G 2n?� ley ft. ft. 1 G
tftl� s Znq� � CAN )ES sR:it
NC beI1:Contracior Certification Numbzr 24Izn ` ;,
T FROM TO DLIMETER MC.Kh-ESS MATERIAL
AL
p ft. ft. 6118 m. SOR-2t
2857`A Dvi,' PVC
Company Name FROM1vERG3S1�GflR.FtBfNG: 'eetiermafelICKNES
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: / ft. ft. 'n
List all applicable Hell construction permits(i.e.UiC',(:omen.,Stare.Variance,etc.) in
ft. f[.
7777777777777777
3.WelfUse(check well use): I:7LSCREEN
Water4Supply Well: FROM TO DIAMETER SWT CtZE THICKhE55 MATERIAL
Agncultural
Municipal%Public ft rt.
�-
Gcothemal(Ticating/Cooling Supply) I
esidential Water Supply(single) ft- tt in
�� esidential Water SupPly(shared) .18-GROUT <:lndustrialiCommercial J FROM TO M.ATHRLAL EMPLACEMENT DIETAOD&-AMOCNT
lrriaation ft- ft.
Non-Water Supply Well: ft. ft.
Monitoring E)Recovery
injection Well.
ft ft.
Aquifer Recharge �Groundwarer Remtdiation
195eiiNf)/GR4VF113 P4GfSflf Itcable) EMPLACEMENTn1ETHOD
Aquifer Stordge and Recovery �Saliniry Bather
FROM TO AIATERLAL
ft. ft.
Aquifer Tcst [3Stormwatcr Drainage
Experimental Technology Subsidence Control
ft ft.
Geotharmal(ClosedLoop) Tracer 26:DItIIf1NC110GaLtaChOESCRIna1ON(c+�t�s"
FROM T: DESCRIPTION color,hat rtec SoiUrocA n e ram it2e Mel
Geothermal(Heatine/Coolin Return) Other(ex lain under=21 Remarks) ft. H.
4.Date Well(s)Completed: - Well ID#
C. ft." ft.
5 .Well Location: ft.
FxilityiOwner ante Faci y 1D (if applicable)
I ft. ft.
ft.
qPhys cal Ad�es�LCily,and Zip ZI:R9wn14RKSl
y
--i•-^'—� ?areal ldentifieation Na(PIN)
County
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certifi n:
(if well field,one ladlong is sufficient) r •••� `^ +
N W
Date
t eturu- Gcitifiid Ni411 Con actor; ,
6.ls(are)the well(s)oPermanent or [37remporary
gv signing this forth.1 hereln;certify That the nrll(si wtS(x'ere)ewutntcted in accordance
th i i,9 NC'dC 02C.0100 or I S.9.NCAC 02C.0200 Well Construction Standards I dolt u
7.15 this a repair to an existing well: �YeS or No copy oflhis record has hecn provided in the :e11 o+v ur.
If rhi is a repair,f/l out known well cnnstmctiotn inlnrrnatia n rplain the nature of the
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
you may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells SUBMITTAL INSTRUCTIONS
drilled:
9.total well depth ow land surface: t S 65 (ft-) 24a. Forn.All Welts: Submit this form within 30 days of completion of well
Fnr multiple seelis list all depths if different(example-3Cic200'and,C 100') construction to the following:
40 (fL) Division of Water Resources,information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service:Center,Raleigh,NC 27699-1617
if[rarer level is above casing,ale +
o sending the form to the address
11-Borehole diameter: 6 �$ (in.) 24b.For Iniection Wells: In addition t in 3�a
above, also submit one copy of this form within 30 days of completion Of well
12 W'ell construction method:
Air Rotary construction to the following:
ti.e°;augur,rotary,cable,direct puslL etc.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Method of test: Air Flow 24c.For Water Supply&Iniection Wells: ht addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs Amount: 1 112 Lbs completion of well construcnoti to the county health department of the county
13b.Disinfection type:�— w}tcrc.cu,s racwd.
yy Revised'__2-2016
North Carolina Department of Environmental Quality-Di�isiou of Water R.esoucces
Form C+K'-1
r