GW1-2022-01842_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD (GW-1) For lnternal Use Only:
1.Well Contractor Information:
Robert Teague _ 44 Ott,► E1z zoi!iS
_ FROM TO .. DESCRIP N
Well Contractor Name � ^ 16 ft. sft.
B&K Well Drilling Inc ft ft
FEB 1 G 20�z _ .
ft. ft.
0 5<)tf CEIt C4 #YG moi>rlca4erl wells q�121vBtt lf'"' air
NC Well Contractor Certification Number 1
2857-A ,� .t ems.v:Jrro•T:iJ Urii• FROM TO DLfMETER� THICKINESS MATERIAL
yes✓� SDR-21 PVC
Company Name 1G INI�TSRCtiS31s1G E1R Fi 1QG eeaimat.etoseit loe s..
FROM TO DIAMETER 11THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft, in.
List all applicable well construction permits f.e.UIC County,State.Variance,etc.!
f[. R•
3.Well Use(check well use):
t7 SC3t EN.
[Geothermal
Supply'W ell: FROM TO DIAMETER SLOT SIZETHICKNESS MATERIAL
ultural ®Municipal/Public ft. ft.(Heating/Cooling Supply) C)Rcsidential Water Supply(single) ft ft. in.
strial/Commercial Residential Water Supply(shared)
TO !•LATERL�i, EMpLACEMENT DtETHOD&AMOUNT
Irrigation ft. ft.
Non-Water Supply Well:
Monitoring Recovery ft.
injection Well: rt. ft.
Aquifer Recharge
[Groundwater Remediation
19:'SAiV�IGlt21\?E'Y,1'4GfC{It' t'
Aquifer Storage and Recovery oSaliniry Barrier FROM TO IILATERML EMPLACEMENT METHOD
Aquifer Test
�Stormwater Drainage ft. TO
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer
28.pItll.LllVCLOG attAchaddtitriid1;31i�etslf. ' > :._, .
FROM TO DESCRIPTION i color,hardrims,solUroel<MW2 rain she,Me.
Geothermal(Heatin Coolin Return) nOther(explain under 921 Remarks) ft ft.
4.Date Well(s)Completed:, i�" Well ID# ft• a tic.
ft. ft.
5a.Well Location: ft. ft.
9 i
n'1► C Y�G_r`�� 1 L1t111�e, ft. {t.
Fa
cili
ty
/Owner Name y� Facility IDk(iffapppliccaable)
ft. ft.
ft.
Physical Address,City,and Zip
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W / — t -aj�
v Date
StEmaturc of Cerificd well Cnn ctnr
6.1s(are)the well(s)OPermanent or [37remporary
By signing this form,1 herel!v cert!fy that the x'ef!(.c)was/x•ere)consin:cted in accordance
7.Is this a repair to an existing welt es or No frith 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
l/'this is a I'epair,rill out known well constrtt on t Duration and explain the nature ofdre copy ofihis record has been provided to the well owner.
repair under 921 remarks section or on the back of is.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 Geon,onlyDPW or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only]�-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .3 4 lft) 24a. For All Wells: Submit this form within 30 days of completiou of well
Fa•multiple we/lc list all depths lfdijfereni(Arample-3ra;700'and i a,100') construction to the following:
10.Static water level below top of casing:
40 (ft) Division of Water Resources,Information Processing Unit,
!f water level 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: construction to the following:
(ix.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f test: Air Flow 24c.For Water Supply&Iniectlion Wells: In addition to sending the form to
Method o
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:
Chlor Tabs Amount. 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
f i
Revised=__:
i �r�016
Form CV.'-1 North Carolina Department of Environmental Quality-Division of Water Resource's