GW1-2022-03966_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD (GW-11
For internal Use On1Y:
1.Well Contractor Information:
td. i17'ER ZONES. DE,SCRir 111i .
Robert Teague FROM TO
Well Contractor Name
L rt. II
B&K Well Drilling Inc ft•
NC Well Contractor Certification Number 7:R E)Kf FERGiLSiNG: reoffa c�d'welk . MATERIAL
FROM TO DIAMETER 1 THICh7gESS
2887-A p ft. 1 ft• 6118 to SDR-21 PVC
at:dosed
16:lNNRRGiSiIGP18$fC1G tbesmlo6 TO MATERIAL
Company Namc 43 3 Q�� FROM DIAMETER THICKNESS
2•Well Construction Permit#:
ft. ft. iin
List all applicable well commucuon permits(i.e.UIC.County,State.Vanance,etc.! in.
3.Well Use(check well use): l;iSGREEN MATERIAL
FROM TU DIAMETER !SWT CIZE THICKNESS
Water Supply Well: fL ft. in.
Agricultural �MunicipaUPublic
. in.
o f[
•(Single)I s ft
na 1 c atin Cowling Supply) Residential Water Stipp y( )
h n (H f'/
Geothermal
e CN tar o i AM s )1 D LL �13:'f.2<i.: :::1:>;> 1 U
residential Water Supply Y l FS M EMPLACEMENT IETH
lndustriaUCommercial FROM To aLA.TERLAL
Irri«ation ft, ft.
Non-Water Supply Well: ft. ft.
Monitoring �Recov cry
r[. ft.
injection Well:
[3Grouudwater Remediation 1 .5 :y P4�:�f kolel 1
Aquifer Recharge FROM TO 9LATERLAL EMPLACEMENT METHOD
Aquifer Stor2ge and Recovery E3StorMy Barrier ft
.
Aquifer TestSotmwater Drainage ft
{t f t pESCKIP
Experimental Technology
Subsidence Control
[3 Tracer 28 DRILf ING 1sOG ttailL addCRIP ION
hue s solvrocl n msize.ctel
Geothermal(Closed Loop) E� FROM To `
Geothermal(HeatinplCoolinjZ Return' Other(ex lain under#21 Remarks) ft. 1 M ft. t —i
1 L f
4.Date Well(s)Completed: - l Well iD# , ft.
'.')-Q� f I. n� r
5a,Well Location: rt. ft.
��`1 ft. ft.
Facility/owner Name Facility
))L tD#(if applicable)
ft. 021-1
Physa:al Address.City,and Zip '_.. .
,2i�;REi►LAeR1�'` ,r t S
rJ\
» Parcel Idenllfic.1Iion No.(?IN) iJ U; i
!• .\i\! tf IU l li
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certifi ont
(ifwell field,one lat/long is suf5cient)
N W
Date
,gnatuno of Ccrtificd Well Cuntrade
6.ls(are)the well(s)oPermanent or [3Temporary
8y signing this form,1lterelry certify,that the xrllLs)Was!w•crcj coturn¢red in accordance
q� �j th L5A NCAC 02C.0100 ur iiA NCAC 02C.o2oo Well Construction Standards'and that a
[Yes 7.Is this a repair to an existing well: or ly l no coyy'of this record has been provided to the v:ell orrner•
1f this is a repair,fill ota knouw well construction information a Tplain the nature of the
repair undm-#21 remark;section or un the bark eif this faun. 23.Site diagram or additional well details:
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 W-1 is needed. Indicate TOTAL NUMBER of wells SUBhfITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple cells list all depths ifdii ferent(trample-3@200'and 2@ 1001
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
lf,vater level is above casing,use"+•
11.Borehole diameter: 6 1 I8 (in.) 24b.For infection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of vve11
12.Well construcI 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
FOR WATER SUPPLY WELLS ONLY: -1636
Method of test: Air Flow 24c.For Water So IV A Infection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one cop}' of this form nithin 30 days of
Chlor Tabs Amount: 1 112 Lbs completion of well.constlucti Ia to the county health department of the county
13b.Disinfection type: where consnvctcd.
North Carolina Department of Environmental Quality-Division of V'ater Rese,rrces Revised 2-22-2016
Form C W-1