GW1-2022-03964_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-�
For internal Use Only:
contractor Information
1.Well Contra :
VY`.A'i`GR ZONFS' DESCRIPTTON
Robert Teague FROM To
Well Contractor Name [S S ft. J
B&K Well Drilling Inc > it. ft
>tS EilfFEftCASI!!IG: m°lfa=casetlt9ells;fliztillll tF M4rER1AL
NC Well Contractor Certification Number FROM TO DIAMETER TMCKNESS
2857-A p ft. ft- 6 1/8 ilu SDR 21 PVC
closed-fog
Company Name 1 .INNF. 11�Gt"'1�t�. DIAMETER, THICKNESS MATERIAL
��) T
2.Well Construction Permit#: FROM TO
v y ft. ft in.
L[s•t all applicable Well construction permits(i.e.Luc,Counrv.State.Variance,etc.) ft• ft.
in.
3.Well Use(check well use): t7 EE]v MATERIAL
FROM TO DIAMETER 'SLOT SIZE THICKNESS
Water Supply Well: it• in.
Agricultural ®Mumicipal/Public
1°
Residential Water Supply(single) fL ft
Geothermal(Heating/Cooling Supply)
R idential Water Supply(shared) Cg:Gl tf1l3
IndustriaUCommercial FROM TO DLATE1tLAL Eb1Pp
LACEMENT METHOD&AMOCiNT
Irrigation ft. fc•
Non-Water Supply Well: it• tt.
Recovery -
__:Monitoring R ft.
injection Well:
oCiroundwater Remediation tkstile
Aquifer Recharge _19•'BAiVfl)G1t9.�1.t1, � MATERLAL EMPLACEME`tT NIETHOD
Aquifer Stor9ge and Recovery �Saliniry Barrier FROM TO
g• ft.
Aquifer Test [3Stormwatcr Drainage
ft
Subsidence Control
tt.
Experimental Technology Z+} 12I1 L3NG.IOD ttaeiLaddte :s1-R "
Geothermal(Closed Loop) Tracer FROM TO DESCRIPTION color.hard s sowroek type. rain sue,cue
Geothermal(Heatin Coolin Return)
Other(ex lain under#21 Remarks) it• ft.
��tt _n,
4.Date Well(s)Completed:S J We ll1D#
Sit it. C�`+�-A.
59.Well Location: fi• ft.
Faci�y 1D9(if applicable)
Facility/Owner Name
ft. ft.
ft. ft.
Physical Address,City,and Zip
33;RCMs4Tlf{5 re r F:
Parcel identification No.(PIN)
County -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certiflca
(if well field.one ladlong is sufficient) K�1t
W J Ei�r v.i i� L
N / Date
Sitalatetn:of Certified W accordance
Well CnntracGn
tricted in actor
6.Is(are)the well(s)>�Permanent OrTemporary
By signing this torn•1 ell Co certify That the xell(s)writ/were)cons
o ,ith I,5A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Wes or co of this record has been provided to the xell owner.
ifthis is a repair, ll[out brown well construction infannatia+and ex gin the nature of the 23.Site diagram or additional well details:
repair under 921 rem+arks'section or on the back of this fonn.
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
constriction details. You may also attach additional pages if necessary.
construction,Only�GW-lisneeded. Indicate TOTAL NUMBER of wells SUBd11TTALINSTRUCTIONS
drilled: /r L
9.Total well depth below land surface: (A (ft) 24a. For All el Wls: Submit this form within 30 days of completion of well
Fnr multiple eve/[c lieu all depths ifdiJJerent(arainple-3@200'and 2@W 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
If water level 4s above easing,use"+"
11.Borehole diameter: 6 1/8 (in.) 24b.For injection Wells: in addition to sending the form to the address inm a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
Air Rotary construction to rile following:
(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:
Method of test: Air Flow 24c.For Water Sunaly&Injection Wells: In addition to sending the form to
M
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs Amount 1 1/2 Lbs completion of well construction to the county' health department of the county
13b.Disinfection type: where constructed.
:' Revised 2-22-2010
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
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