GW1-2022-03927_Well Construction - GW1_20220412

WELD ONSTRUCTION RECORD SM-Al
For Internal Use Only:
1.Well Contractor Information: iq ;ill RZONt S
Robert Teague
..FROM TO DESCRTPTION
ft. 3.6 0 rt. /--
Well Contractor Name
6 _ ft.
B&K Well Drilling Inc JS ft.
1C OIfFEg CASiivG mstti' vvisl]s`tlR±G1l51 1t S hL4TERIAI
DIAMETER
'1'HICI4NESS
NC Well Contractor Certifi TO cation Number FROM PVC
ft. ft i 1!8 im SDR 21
2857-A ° tiiesnaot ddsealib
%:16<INNER:E $INGt)R EU$ING THICKNESS MATERIAL
Con any Name FROM TO DIAMETER
f[. in.
2.Well Construction Permit#: ft.
o
List all applicable"all construction permits(i.e.UIC,Com yule.Variance,etc.l ft. tt. -
3.Well Use(check well use): L7i`SF3ZE£1� MATERIAL
FROM TU DIANI ER SWT IZE THICKNESS
Water Supply Well: g- ft. in.
Agricultural []Municipal/Public
ReSidcntial Water Supply(Single) ft. ft
m
Geothermal(llcating/Cooling Supply) Supply(shared) EMPLACEMENT AIETHUD S.�moltl,T
lndustrial/Commercial RasidantialWaterSupp. ( FROM
bt�tERltf
PROM To
ft. ft.
lrriaation
Non-Water Supply Well: ft. ft.
E)Recov'ery
Monitoring
injection Well: llciblel ''
Aquifer Recharge [3Ciroundwater Retnediation IyjyjGgAVELf iC1C EMPLACEMENT METHOD
Salinity Barrier
FROM TO AIaTERL4L
QAquifer Storage and Recovey ft. ft.
13 Aquifer Tcst Stormwatcr Drainage ft ft
ISubsidenceControl ttactsa&di8oniiFsnecess rain size,ct�i
E>perimantal Technology Z9:IiRI1 E31�C:1 OG.
Tracer FROM 70 DESCRIPTION lor. ncss soiViock
(-,eothermal(Closed Loop) [3Other(ex lain under#21 Remarks)
g, ft. C
Geothermal(Heatin Coolin Return) 1�S tc )L 0 5
W ID#
tt �� •�
Well S jJ
4.Date Well(s)Complet ft. IS 5 ft. )/
5a.Wen Location: ft.
1^
tt.
y
L tt. r
Facility tDk(if applicable)
Facility1wwrierNanve ft. ft. •�" ,
rt rt
physical Address,City.and Zip 23_REM RKS>
parcel identificuion No.(PTN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certi 'on:
(if well field,one W/lone is sufficient)
W
N xtu
$ lature of Certified Well tractor;
6.Is(are)the well(s)OPermanent or �Tempnran'
gy signing this(ono,I heretry cerd6,.1hat the iiell(l)war(,,cc)cot�rnicred in accordance
:l ith 1.5A NCAC 02C.0100 or 15A NCAC 02C'0200 Well Cunstruct on Standards and that n
7.Is this a repair to an existing well: Yes or No cop.of this record has been provided to the xr o„'turn.
out knonm well construction infannanar° rrplain the nature of the
/f'this is a repair,fill 23 Site diagram or additional well details
repair under 921 rennar•ks sea•6on or on the buck of this funn. 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.
constriction on 1 GW-I isneeded. indicate TOTAL NUMBER of wells SUB�IITTALINSTRUCTIONS
drilled: j
9.Total well depth below land surface:
(ft) 2qa, For 411 Wells• Submit this font within 30 days of completion of well
For multiple nelLc Liar all deptics i(different(trample-3'�e'_'00 and 2 ct_J,10(1) construction to the following
40 (ft) Division of Water Resources,information Processing Unit,
617
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 276990 the
in 24a
il'aiater level Ls allom casing,use"+" the forin
6 1/8 (in.) 24b.For-In fection Wells: lofdthis form within 30 days of completionsof wall
11.Borehole diameter: above.also submit one copy
Air Rotary construction to the following:
12.Well construction method:
(i.e.auger,rotary,cable,direct push.etc.) Division of Water Resources Underground injection Control Program,
,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Air Flow 24c.For Water SuapIV&Infection Wells- In addition to sending the foes to
of
13a Yield(gptn) Method of test: the address(as) above, also submit one copy of this form within 30 day
Chlor Tabs Amount-
1 1/2 Lbs completion of well construction to the count}' health department of the county
13b.Disinfection type: where construac .
Revised'_-2'_-'_016
North Carolina Department of Environmental Quality-Division of Water Resources
Form GW-1