GW1-2022-03933_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW_1)
For Internal Use Only:
1.Well co
ntractor
trac t r Information:
Robert Teague FROM TO DESCRfPTTON
Well Contractor Name
B&K Well Drilling Inc 3 Lt S ft.
t5 0t)CE1tCA51N rmCtavESS K-ATEtt1AL
NC Well Contractor Certification Number FROM TO
2857-A p ft. Sft METEx in 6 1/8 SDR 21 PVC
tzn rrosaane
161NNER C=aRTU$lI!tG THICKNESS MATERIAL
Company Name ���y FROM TO DIAMETER
2.Well Construction Permit#:
VX ft.
List all applicable well cotsiruction permits(i.e.VIC,Coerry,Sture.Yuriunce,etc.) ft• ft. in.
3.Well Use(check well use): 1,7• EEN - T SIZE MATERIAL
FROM TU DIAMETER SW THICKNESS
Water Supply Well: fL ft• in.
Agricultural �MunicipaUPublic
ft.
in.
ft I (single)
' olio Su ly) -Residential Water Supply:)Geothermal(Heat rig/ g
esidential Water Supply(shared) tt3 CGt7D11�
lndustriaUComntercial FROMTO 11LATERLAL EMPLACEMENT NfETHUD&ANiODNT
Irriaa[ion ft. ft.
Nun-Water Supply Well: ft. ft.
Recovery -
Monitoring ft ft.
injection Well:
Groundwater Remediation &tittle
..'.Aquifer Recharge 19' ANDTGRTO 4GK.N(ATERLAL EMPLACEME TMETHOD
Aquifer Storage and Recovery [)Salinity Barrier FROM To
ft. ft.
Aquifer Test �Stormwater Drainage ft.
Subsidence Control
ft
Experimental Technology 29. Ri}L31VG:It1�:'ffaeli'8ddieoaasfa
(Jeothermal(Closed Loop) Tracer FRONI To DESCRIPTION color.his ccs soWroc k n a nafnsize.cta)
Other(explain under 021 Remarks) ft. ft. 16'
Geothermal(Heatin Conlin Return) -
1 We11iD# —5 ft. ft.
4.Date Well(s)Completed: c.
59.Well Location: ft. ft.
�16M � ft. ft.
,.. Facility IDk(if applicable)
Facility/Owner Nance ft, ft.
A r>-t S I (� � tt. ft.
11 JJ
Physical Address,City,and Zip
D r� :.11:1t,E1►is}RKS <: .
Parcel identifietition No.(PiN)
County��
5b.Latitude and longitude i degrees/minutes/seconds or decimal degrees: 2�2?
22.Certfifficatiopl
(if well field,one lat/long is sufficient) 4i.�'uru
Ncnificd W lCnnna. > �1f t`6.is(are)the well(s) Permanent or Temporary13 signing this tore.1 hereltv Co certify That the xcllLs)was(wrre)constructed in accordance
g No rr'ith I SA NCAe 02C.0100 ur 1 sA NCAC 02C.0200 Well Construction Standards r+rid that o
7.Is this a repair to an existing well: Yes or 0 co otihis record has been provided to the xrll owner.
q'this is a repair,ill out known well construction information and sprain the nature ofthe 23.Site diagram or additional well details:
repair under f12/tenon d�section or on the bunk ajrhis turn. 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. Indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled: ��
drilled
9.Total well depth below land surface: (fL) 24a. For Ally: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(atmnple-3@Yg'and 2 a 1001
construction ction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
h
1617 Mail Service Center,Raleigh,+NC 27699-1617
11,rarer level is above casing,use•+
11.Borehole diameter: 6 1/8 (in.) 24b.For infection Wells: In addition to sending the form to the address f well
above,also submit one copy of this form within 30 days of completion of wall
Air Rotary construction to the following:
12.Well construction method:
ti.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: Air Flow 24c.For Water Suouly&Infection Wells: In addition to sending the form to
13a•Yield(gpm) the addresses) above, also submit one copy of this form within 30 days of
Ghlor Tabs Amount: t 1/2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type: where consnvctcd.
Revised 2-22-2016
North Carolina Department of Environmental Quality•Division of Water Resources
Form GW-1
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