GW1-2022-01865_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD (GW-1) For internal use Only:
i.Well Contractor Information:
Robert Teague ;:;
g _ FRONT TO DES;CRrPTION
Well Connector Narrre ku�5 � U ft. i ��t• 1
B&K Well Drilling Inc rt. ft.
FEB 16 2027
NC Well Contractor Certification Number YS:pt)°fEfYCiSStNGF ($aitfc> :`relk f11 AN A11
FROM TO DIAMETER THICKNESS MATERIAL
28rj7-A �ja.�Uriii p ft S tt 6 its SDR 21 PVC "
ContpanyNamc FRROM.I TO DIA M .�
1ON \TERG1Sil`1GE3RFi I
C}-/� METER THICKNESS MTERIAL
2.Well Construction Permit#:_ ft. ft. in.
List all applicable mall corutmerion permits(i.e. _11C.County,Stare.Variance,etc.)
f[. ft. in.
3.Well Use(check well use):
)
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Publii fL ft. In.
Geothermal(Hcating/CoolingSrpply) Residential Wa cr SuPP1Y(single)) tt
ft.
In.
Industrial/Commercial WaterSupply(shared)
FRONT TO NUTERLIL EMPLACEMENT DtEIHOD&11MOUN'f
lrriQation ft. ft.
Non-Water Supply Well:
nReco\'ery ft. ft.
Monitoring
injection Well:
Aquifer Recharge E)Groundwater Remediation
iJi �iG��Eils�
..:...................
Aquifer Storage and Recovery Salinity Barrier FRONT TO
ft. nUTERLAL M
EMPLACEME>t'1' ETHOD
Aquifer Test []Stormwatcr Drainage
ft,
Experimental Technology
Subsidence Control ft. ft.
Geothermal(Closed loop) FJTracer 2�ii7#RI1rY3P7it) etackDESCRInBia .a'f n. ilme
FROM TO DESCRIPTION(mbr.ha ncss,solUrcek b in size,etc.)
Geothermal(Heatin Coolie Return) ^ Other(ex lain under#21 Remarks) ft. R.
4.Date Well(s)Completed:
eLI Well ID# ft. ft.
f[. ft.
Sa.Well Location: � ft. ft.
�e✓S
ft.
Facility/ er Name Facility loft(if applicable)
ft.
ft. ft.
ft. ft.
Physical Address,City.and Zip
. .::. ........
V%�
Parcel identification No.(PiN)
County
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 C¢rhfc
(if well field,one lat/long is sufficient)
rp7iatunofCertificdWel ontractor. Date
6.Is(are)the well(s) Permanent or Temporary
8I signing this form,1 hereby certifyrhar the xellisl was M'crc)rnnsrtucred in accordance
rrth 1 SA NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that n
7.Is this a repair to an existing well: Yes ar No copy-of this-record has been provided to the well owner.
if this is a repair,fil out known well construction informationan .rplain the nature of the
repair under 021 remarb-s section or on the hack of this/orm. 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 constriction details. You may also attach additional pages if necessary.
construction,only 1 GW 1 is needed. In TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well dept below land surface: ®� (ft) 24a. For All Wells: Submit this form within 30 days of Completion of well
For multiple wells list all deptlis i(difterent(arainple-3 @200'and 3 rci 1001 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
If water level is above casing,use
6 1/8 24b.For infection Wells: in addition to sending the form to the address in 24a
11.Borehole diameter: (In') above,also submit one copy of this form within 30 days of completion of well
12.Wen construction method:
Air Rotary 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 Mad Service Center,Raleigh,NC 27699-1636
Method of test: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
13a.Yield(gpm) the addresses) above, also submit one copy of this form rithin 30 days of
Chloe Tabs Amount: 1 112 Lbs completion of well construction to the county'health department of the county
13b.Disinfection type: where consttuctcd.
North Carolina Department of Environmental Quality.Division of Water ResoLes
Revised 2-32-2010
Form Ow.1