GW1-2022-03962_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD GW-11
For Internal Use Only:
1.Well Contractor Information:
td WATER ZONES. D&sCRrPTrON
Robert Teague FROM TO
Jc +j rt. Sit.
WelI Contractor Name
ft 7 .. ft. iU ", ..
B &K Well Drilling Inc -
1 >OU EEIt CASit�T4 iitiiiii lls OR:L'1t Rif tttATER1AL
NC Well Contractor Certification Number 'IMCKNES$
FROM TO
2857-A 0 ft. ft- 6 V8 SDR-21 PVC
Company Name (' 3b lM1VESCA51l!tG4R Ft18
MATERIAL
FROM TO DIAMETER THICKNESS
2.Well Construction Permit#:
ft. fL I in
List ali applicable well Coturruclion permitsermits(i.e. State.Variance,etel ft tt. in.
3.Well Use(check well use):
17i:$GkE£N - MATERIAL
er
FRUFROMTU DIAI[I ETER yWT SIZE THICKNESS
at Supply Well: ft ft. in.
Agricultural �MlmicipaUPublic
Coolin Su ly) RCSidcntial Watcr Supply(Single) ft ft.
- catln g PP
al Tn (1l
Residential Water Supply(shared) �;i�pj�'
IndustrialiCommercial FROMTO rL&TE1tL[I EdrpLACEME1rT
imaatton g- ft. DIETHUD&AMOUNT
Nun-Water supply Well: ft ft.
Recovery
Monitoring ft,
tt.
injection Well:
Groundwater Remediation 1y*. A.5 p gAy�#r
Aquifer Recharge 4Gtt'�IATERLAL EMPLACEMEVT aIETHcgD
ft.
Aquifer Storage and Recovery Salinity Barrier FROMft.
Aquifer Test C)Starmwatcr Drainage
Subsidence Control ft tt ,
ErperimeDtalTechnology 2ll:bRlLiII!15.:1 ttacadebbii�3e '
geothermal(Closed Loop) Tracer FROM To DESCRIPTION mlor.h nccssot
utockn nnnsuc,ecel
Geothermal(Heating/Cooling Return' rI
Other(es lain under#21 Remarks) ft,
tcy� ft, ft.
4.Date Well(s)Completed"t' S-�� Wel1ID#
c5 ft. ft. 1
5a.Well Location: ft. ft.
ft. ft. ^ T k
Fatuity/Owner Name Facility LDK(if applicable)
f ft. ft.
e 7 cf A
reis.City,and Zi _.
Physeal Add P w is
l.s-'1 TLC�/ — :e y,rfrtt ll V N
Parcel Identification No.IPIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certif 'on
(if well field,one ladlang is sufficient)
ate
tataturo of Certified Well Contract
6.1s(are)the well(s) Permanent or Temp°rare
gr aaturt, this tore.]Well
C!v certify that the xcll/.g)was(w'ere)con in accordance
�y 'th 1.5A N'CAC 02C.0100 or 1 iA NCAC 02C.0200 Well Construction Siandards red that n
7.is this a repair to an existing well: E)Yes ar N° ropr ofthis record has hecn provided,tn t/re xrll ort-ner.
(/this is a repair,fill tan known""construction information n rplain the nature otthe �3.Site diagram or additional well details:
repair under#21 rental-A,;section or on the back ojthis Lunn.
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 construction details. You may also attach additional pages if necessary.
construction,onlyIGW-I is needed. Indicate TOTAL N U MBER of wells SUBhtITTALINSTRUCTtONS
drilled: —
9.Total well depth b ow land surface: 3 0 (ft) 24a. For All lls We : Submit this form within 30 days of completion of well
Far multiple wells liar Ali depdiv itdiff'erent(eratnple-3C+200'and i a,100')
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
!%.cater level is above cncing,use"+
11.Borehole diameter: 6 1/8 (in.) 24b.For iniection Wells: in addition m sending the form to the address in_
above.also submit one copy of this fomg within 30 days of completion of well
12.Well construction method:
Air Rotary construction to the following:
t i.e.auger,roury,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 So I &Iniection Wells: In addition to sending the form to
Met
13a.Yield(gpm) the address(es) above, also submmt one copy of this form within 30 days of
Chlor Tabs 1 V2 Lbs completion of well constructionto the county health department of the county
13b.Disinfection type: Amount.
where cunsalrcted.
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 3-3_'-_'016
Form OW-1