GW1-2022-03940_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague FROM TO DESCRTPTION
Well Contractor Name ft. ft.
B&K Well Drilling Inc ft. rt.
NC Well Contractor Certificati m Number 36z:91fFEdtGit ltVGE ': ii11ii34iw%
FROM To DLAMETER TffiCKNESS MATERIAL
2857-A U ft. Ci ft. 61/8 ` SDR-21 PVC
Company Name �( (�
lJ \ �� 1fi:l3?iiER�3511�1a"s4R�
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rc. ft. to
List rill applicable Nell construction permits(id.U1C,Cowgv,State.Variance,etc.)
ft, ft. in.
3.
Well
Us
e(check well use):
: __....... ............. ..
Water Supply Well: FTtoal TO DIAaETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMlmicipal/Public tt ft. in.
Gcothennal(Hcating/Cooling Supply) Residential Water Supply(single) rt ft ib•
es, ennal Water SuPP]Y(shared) , ;;:;.::•>:;;>:<•;::;;; .....:;:< ;:o;:::
Industnal/Commen,tal .
:.....::......:.........:.
FROM TO DLATERLAL EMPLACEMENT INWMOD&.AMOUNT
ltriaation ft. it
Nun-Water Supply Well:
Monitoring 13Recocery _ ft. ft.
Injection Well: ft. ft.
e Remediation :.
C,roundwat r _.,:.:....._
Aquifer Recharge Q 1>3;Sq�t#Ni�RAk :f Af4S dSG ::::.::::,:..,::•::::..::::-::
tETaoD
Aquifer Stor9ge and Recovery Salinity Barrier FROM To ALATERLAL EMPLACEMF`rr n
Aquifer Tcst []Stormwatcr Drainage
ft. ft.
Subsidence Control
Experimental Technology �
Geothermal(Closed hoop) nTracerEipl0O ]ON Golf ,tugs in ,etc)
FROM TO DESCRIPTION color.Mrdna Uroek•• in size,etc)
Geothermal(Heatine/Coolin Return Other(explain under#21 Remarks) R, S R.
4.Date Well(s)Completed:a—3— Well iB# ft. rc.
tt. S v tt.
5a.Well Locatiop:
l Sft. US ft. ^'
Facility/Owner Name Facility 1DK(if applicable) f5 5
ft, t.
rt, f ft.
Physical Address.City,and Zip L i
_............. ..:.
i
T
i V ► S
County-7 r arcel ldennfieation No.(?TN) --
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
APR 2
(if well field,one lat/long is sufficient) 22.Ce
N W vuei
sipaturc ufCcrtificd cllCunvacto R zz"Tjj
6.is(are)the well(s)opermanent or Temporary
Br signing this fibrin,1 hereby certify that the aril(s)svac(Here)cwnsinicted in accordance
7.Is this a repair to an existing well; E)Yes or No "'ith 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Cuiurmcriun Surndarth and that a
If this is a repair,ell ones btow7 well construction information and .rplain the nature o(rhe cop}o(this mcmd has been provided to t/te Nell oltner.
repair under 021 rein -ib--section or un the back ojthis juror. 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v (fL> 24a. For All Wells: Submit this form within 30 days of completion of wall
Fnr multiple wells list all depiht ifdiJfereni(example-3 @-'00'and 2 a 100� construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
ffrwter level is above casing,use- 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (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•rowy,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
13a.Yield(gpm} Method of test Air Flow 24c.For Water Sunnly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tales Amount: 1 112 Lbs completion of well construction;to the county health department of the county
where conscrictcd.
Form GW-1 North Carolina Department of Environmental Quality•Division of Rater Resources Revised 2-22-2016