GW1-2022-01855_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague _ 14.wArRzox>
Well Connector Name r-t - _ FRONI TO DESCRIPTION
B &K Well Drilling Inc �t 7 a �'
Uflfl
NC Well Contractor Certification Number �� '
!'y!'r i�'t5
i:it5i bU'FER Gr15i1\1G:#'or'6ini6rcesed;<'sirils'i3K_�14VI+.IY'
2857-A FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ft. 6119' m' SDR•21 PVC
Company Name
\` \ if:JIYI+IER '' {;;R'FifBtMG t�esmat:el
2.Well Construction Permit#: �y� \ — O � FROM I TO I DIAMETER I THICKNESS MATERIAL
list all applicable well eonsrmetion permin 4 UIC.Cowrrv,State.Variance,etr.) ft. ft. in.
3.Well Use(check well use): ft• tL in.
Water Supply Well: FROM TO DIAMETER SWT SIZE I THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
:)Industrial/Commercial esrdenual Water (shared) ::>:;:�>i: i:::i.s.:<:�i :i;:f::;_::.::.:;.:.;.::;._:;..:.<..;..;..;..;.:..;..:.:.>.i.x....;..:.�.s......;.:.2..:..::.�.;..i..',�..;..:..:..i..:>_....�;...i..>.:.�_'�.;..;.,i:..:.:_:.�..;...:....::................_.........
Irrigation FROM TU !•LATERLAL EMPLACEMENT METHOD&AMOUNT
Nun-Water Supply Well: ft. ft.
Monitoring DRecovery
Injection Well:
Aquifer Recharge ElGroundwater Remediation
193Ai�f)1Gtt}VELIPACKAU.400064W
Aquifer Storage and Recovery Salinity Barrier FROM TO 51ATERL4.I. EMPLACEMENT AIETHOD
Aquifer Test E)Stormwatcr Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 28<BRI1vII1NG:LOti Citliaild+fl6t19#slteeq ::
FROM I TO DESCRIPTION color,hardness,so roel.n grain sin etc)
Geothermal(Heating/Cooling Return) nOther(explain under 21 Remarks) ft. ft
4.Date Well(s)Completed: Z Well ID# tt, e k _}C—
ft. ft.
5a.Well cation:
COyxC u ft. n.
Facility/Owner Name Facility ID0(ifapplic le)�
L 6 4
Physical Addw4s.City,and Zip ft. ft
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County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if weal field,one lal/long is sufficient) 22.Certification:
N W
6.19(are)the well(s)oPermanent or E31remporary Si •tun of Certified Well tractor Date
Bi-signing this form,1 herebv certify that the xvil(s)wac Nerc)consrrnered in accordance
7.Is this a repair to an existing well: [)Yes or QN.J. virh 15A NCAC 02C.0100 or iSANCAC 02C.0200 well Construction Standards and that oIj'this is a repair, 111 out kno%v well construction infarmarion din the nature of the copy ofthis record has been provided to due xr l/ouncr.
repair under 921 remarks section or on the bark of this;fw,n. 23.Site diagram or additional well details.
S.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,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth Blow land surface: (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple nrlls list all depr/u iftliferew(example-3`200 and 2 r@1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of water Resources,Information Processing Unit,
jwarer level is above casing,use-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /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 the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Aiail Service Center,Raleigh,NC 27699-1636
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73a.Yield(gpm) �� Method of test Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
the addresses) 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 constructor to the county health deparnnent of the county
where constructed.
Form GW.I North Carolina Department of Environmental Quality•Division of Water Resources Revised 2-32-2016
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