GW1-2022-01858_Well Construction - GW1_20220216

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague
-sm FROM I TO DESCRIPTION
We]I Contractor Name
v Cy..��..,, '�' 3
B&K Well Drilling Inc it. 7 D it. 0 r
FEB 16 2022
NC Well Contractor Certification Number 15:(k)FEl7.Ci1j�iG ':.osa#rcased:av v1&#ilft'lt'
2857-A FROM TO DIAMETER TfnCK"74ESS MATERIAL
1r�'r: p
� ft ft, 61/8 in. SDR-21 PVC
In;� a.
Company Name � 1�
ul?' i6-,1bNfK4CAS1NG0. R'Fil$fNG' eef tfmdf:tltisedfoe
2,Well Construction Permit#' � FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. In
List all applicable well construction permits(i.e.UIC.(:'oanrv,State.Variance,etc.)
f[. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public tt rt. in.
Geothermal(Hcating/Cooling Supply) sResidential
Residential Water Suppl
y
(single) , in.
IndustnaUCommerctal Water SuPPIv(shared)
Irrigation FROM TUMLITERLAL EMPLACEMENT MtETHOD&9MOL+NT
I. ft
Nun-Water Supply Well:
Monitoring [31tecovery ft. k.
Injection Well. ft. ft.
Aquifer Recharge Groundwater Remediation
0 SANfNG1>`AVE—L3 tlCie`Gf hcetile.
Aquifer Stor9ge and Recovery []Salinity Barrier FROM TO ML4TER1 L EMPLACEMENT METHOD
Aquifer Test [3Stormwatcr Drainage ft. ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop)
Tracer 2&TfRII)ING:#U atfaeeddlFieri#31teEt� .
FROM TO DESCRIPTION color.hiirdness.solUroeA con stzc cte.l
Geothermal(Heating/Cooling Return) ,Other(explain under 921 Remarks) ft /> ft. 1 .0 \
�7
4.Date Well(s)Completed: }� ` Well ID# ft. ft. 1 i _P.
fL V f4 Q S 6
5a.Well Location: V 3 c>
\nJ��5 Ir
'r� A C
FacilityLDk(ifa luable) ft. ft.
Facility/Owner `t,� `f (7 �11 PP
�h Y\\1 N e, r V ft. ft.
ft. ft.
Physical Address,City,and Zip
Lk Vq-�Iy-iik
County Parcel identification No.(?IN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Cc :fi�
�
N W
taturcofCtaified Contrdetor, r Datc
6.Is(are)the well(s) Permanent or Temporary
By signing this/Drat.I herelry certin?,1 ar the well(s)+vas(uere)concsrntcted in accordance
1.Is this a repair to an existing well: 13Yes or N0 vith 15A NCAC 02C.0100 or 1jA NCAC 02C.0200 well Construction Standards and that a
If this is a repair.ill our knoxm well construction information an crplain the nature of the cope of this record has been provided is the xrll o+rnt r.
repair under AE21 remarks section or on the hark of this.form. 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: ASUBNlITTAL INSTRUCTIONS
9.Total well deptJ below land surface: L4 v r, ---> (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/Lc&(t all depths ifdiiereni(aranple-3@ 200'and 2@1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use..+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 118 (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 Mail Servit:'e Center,Raleigh,NC 27699-1636
13a-Yield(gpm)
Method of test: Air Flow 24c,For Water Supply&c niection Wells: III addition to sending the form to
the address(es) above, also submit one copy of this form tvlthin 30 days of
Chlor Tabs Amount: 1 1/2 Lbs completion of well construction' to the county health department of the county
13b.Disinfection type: where constructed.
Form GV.'-I North Carolina Department of Environmental Quality-Division of Water Resources Revised=22-2016
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