GW1-2022-03965_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD (GW-11
For internal Use Only:
1.well Contractor Information:
WAi:I'ER DE•SCRiP7TON
Robert Teague FROM To
Nell Contractor Name
Sit. 1 ft.
B&K Well Drilling Inc it ft
©Kts11�iC'
NC Well Contractor Certification Number 1� OMIERCAbNNG kilk sed's � imss K%TERL4L
FROM TO
2857-A 0 ft. 5ft. DIAMETER'f/8 SDR-21 PVC
1S:1NfvERi=t>R fT#B11�tG mati[osce ttie
ContpanyNamc �n FROM TO DIAMETER THICKNESS MATERIAL
t l
2.Well Construction Permit#:J
f[. ft.
List all applicable Well cortstruetion permits(L(e li1G'.County,Stale.Yana C etc.) ft. ft.
3.Well Use(check well use): IT::SCREEN
FROM TO DIAMETER .:.SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft ft In.
Agricultural �Mumicipal/Public
atin 'Conlin Supply) Rcsiden6al Water Supply(single) ft tt.
iTlal(Hc g
r .
Geothermal ,...:.
Residential Water Supply(shared) 18;CsTrUIIT :`:.: ` Ehfpl ACEMENT 1IETHUD&AMOUNT
lndustrial/COmmefcial FROM TO DLITERLAI
irrigation ft. ft.
Nun-Water Supply Well:
Monitoring
Recocery
tt, ft.
injection Well:
Aquifer Recharge �C,roundwacerRemediation >5AN .Y, gs�iK:{1f `'ltieble? eMPtAceME�r+�erHOD
FROM TO �l4TERLAL
Aquifer Stor2ge and Recovery E3Saliniry Barrier ft
it.
Aquifer Tcst oStolottwawr DTainagc
Experimental Technology oSubsidence Control
ft. ft
26 D1tILI11VG'LO ALt$Elt:afTd1$OLnt3 l
Geothermal(Closed Loop) Tracer FROM to DESCRIPTION color.hard s so It kb rn size,ere)
Geothermal(Heatin Conlin Return) (ex lain under#21 Remarks) ft. -S- ft. G
_ 7 . ft.
4.Date Well(s)Completed: Well ID#
655. Sit.
5a.Well Location: ft. ft.
ft. ft
Facility/Owner Name Facility 1D"�(ifapplicable) y
j l ft. ft >. r r w ! : rre
ft
REi)i
Physical Address,City,and Zip
e'tRKS`.<
Parcel identification No.(PiN) 6 .• v f t� e
County ... ., - �,;t•.:v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �2 Ce atio
(if well field,one latJlong is sufficient) L�=/ ���
N W G
Date
Si�tatum vfCcnificd W� Contractor
6.ls(are)the well(s) %permanent or �Temporan'
13ti signing this tiono.1 herclo rrrttfi'that the vcll(sJ was!were)consrna;rcd in accor ance
�N ��ith 1 SA NCAC 02C.0100 ur 1 j d NCAC 01C.0200 well Construction Standards and that a
7.Is this a repair to an existing well: E)Yes or E N0 co o((his record has hecn provided in the well o%iTer.
//'this is a repair,fill out knoxw well cnn.51 u 1iat:nfnnnatinn a����'nd eteee�-Plain the nature o(the Site diagram or additional well details:
repair under 921 reniar-A-s section or un the back ojthis for 23.
m. 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,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells SUBMITTAL INSTRUCTIONS
drilled: "�
Sets (ft-) 24a. For All Wells: Submit this form within 30 days of completion of welt
9.Total well depth be ow land surface: construction to the following:
Fnr multiple wells/W all deptlu ifdrr fereni(ecrmnple-3@200'and 2 a 1001
40 (ft) Division of Water Resources,Information Processing Unit,
10.Static water level below top of rasing: 1617 Mail Service Center,Raleigh,NC 27699-1617
11*unrer level is al'o-casing,ace"+
6 �f 8 For Tniection Wells: In addition to srnding the form to the address in'_4a
11.Borehole diameter: (1°') 24b.above,also submit one copy of'this form within 30 days of completion of well
12.Well construction method:
Air Rotary construction to the 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:
the form to
Method of test: Air Flow _ 24c.For Water SunDly&Iniection Wells: In addition to sending
13a.Yield(gpm) the addresses) 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 count}' health departrnent of the county
13b.Disinfection type: where consnucwd. i
Revised=-22-1_010
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources