GW1-2022-03932_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD GW'll
For internal Use Only
1.Well Contractor Information:
''tAc'VtFi17�R7A3vES:::.. ....DE.SCRiPTtONI -
Robert Teague FR001 TO -
Well Contractor Nameit / v�
B&K Well Drilling Inc L
": wells t)Riie11!>g tt •M-42ERML
'.:25:.: ..ERGA51!?I.' DIAMETER THICK
NC Well Contractor Certification Number FROM T pVC
ft ft 61l8 �' SDR-21
2857-A °
16<1N1VER Gf3R:E(i13�AtG' Iak zltAed-ttM M.TERIAL
Company Name FROM
TO DIAMETER THICKNESS
it. in.
ft.
2•Well Construction Permit#: ih
LiS[all applicabie u,11 eo,Ltlnlction permas(i.e:.U1C.t.atlle(te.$laffi.VarlaifGC,CIC/ ft. ft. _..-
::.:.::
TSIZE
3.Well Use(check well use): t:FROM TO DIA3.SC31EEh.. METER THICKNESS MATERIAL
gt,O :
Water Supply Well: fL tt. 1n.
�MunicipaVPublic
Agricultural tc.
. n.
Rcstdcnnal Water Supply(single) ft
I m Supply) t
Gcothcnnal(Hcadng/Coo g PP :
Supply(Shared)ResidenualWater Su ly( i$>�nIIT ''" rL�TERLIL. EhtpLACEMENTD�.'1'HUD&-MiOLtN'I'
industrial/Commercial FROM To
ft. tL
irri-ation
Nun-Water Supply Well: ft. ft.
�Recocery -
Monitoring tt. ft.
injection Well:
Groundwater Remediation .1.:.SfljC; y-ELP4Cff'{tt' ..ltcable EMFLACEME`tT METHOD
Aquifer Recharge hL&TERLAL
TO
oSalittiry FROM Barrier it. ft.
Aquifer Stor#ge an(l Recovery oStormwatcr Drainage
Aquifer Test
oSubsidence Control �,n size etc t
Experimental Technology 2A lR1LE iNG:1iOG itsels tidtfioiietalts
Geother al(Closed LOOP)
Tracer FROM TO DESCRIPTION color.hardness.301VMel.to
Otber(ex lain under t21 Remarks) tt, O R.
Geothermal(Heatin Coolie Return) tt. 0 1, e
tt.
► elllD# fL
4.Date Well(s)Completed: 4V' ft.
Sa,Well Location: .
ft. tc.
t� 1 ft. ft.
1 Cll )' t Facility lD"'(if applicable)
Facility ante / l ft.
y
- �f it it
l hyS� al `
and Zt
Physical ddress,City. P �V 1 '�'•t ' F
21'.RE11L�t;RKS
�ti n No.(PiN) d•.Ji c:..vi I"IA
Parcel identifie. o
County I'tc.11�a7�6ttJ UI\(i�
r decimal degrees:
5b.Latitude and longitude in degrees/minutes/seconds o 22 Certific do � �._
(if well field,one latllong is sufficient) Lr�^' 1 r� I
N W ✓/
Date
$ stun:of Certified Well G uadnr
Tem orar}'
6.ls(are)the well(S) Permanent or P g,.ctga;ng this form.1 hercfw certifi that the xrlhs) li Constructio t Sfemdardird in s rrnd that u
"ith 1.5A NCAC 02C.0100 ur 13-4 A'CAC 02C.0200
7.Is this a repair to an existing well:
Yes or No cops of this record has been provided to the x2ll o a'ncr.
1(this is a repair.ill mu know"well construetiae infarmatinn a d rplain the nature o1 sire 23 Site diagram or additional well details:
repair under q21 remarh;seutiun ur un III,hack 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.
consmiction,only GW-lisneeded. indicate TOTAL NUIVIBERofwells SUgN11TTALINSTRUCTIONS
drilled: �( 11
9.Total well dept below land surface:
(} lJ (ft) 2da, For All Wells: Submit this form within 30 days of completion of well
Fo n[ultipie uY/lc fiat all depths ddii ferent(nrev^ple-3'a'_'00'and?�/00� constntc[ion vi the YollWate_:
(ft) Division of Water Resources,lnformation Processing NC 27699-1617 nit,
10.Static water level below top of casing:40 1617 Mail Service Center,Raleigh,
1f,.uter ieve!is ahore casing,use"+" the form to the
6 U8 (in.) in 24a
24b.For infection Wells: inoafdthtfs form wrthtm 30 days of comp completion will
11.Borehole diameter: above. also submit one copy,
Air Rotary construction to the following
12.Well construction method: :(i.e. ces,Underground injection Control Program7
auger.rotary,cable.direct Pusb.etc-) Division of Water Resour
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY K�WELLS ONLY: i
Air Flow 24c.For Water Supply&Infection dells: In addition to scndiug the dots o
Method of test: addresses)ses) above, also submit one copy of this form within 30 day
13a.Yield(gpm) P health department of the county
Chlor Tabs t t!2 Lbs completion of well con;tni loon to the count}' P
e Amount: where consnUctcd.
13b.Disinfection typ '
Revised 2-22-2016
North Carolina Department of Emircnmental Quality-Division of Vd o
ater Rlsurres
Form Gw-1