GW1-2022-03968_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD (GW_ll
For internal Use Only:
1.Well Contractor Information:
14 WATER ZtJ*IES>� DESCRiPTTON
Robert Teague FROM TO
Well Contractor Name b ft. 6 ft.
B& K Well Drilling Inc ft.
ft.
yeas oR:i,11�t tf:
1S'UflTERGASti`fG ..,ttistts-cased 78ICKNESS MATERIAL
NC Well Contractor Certification Number FROM TO DLfMETER
2857-A ft. E. fi. 5118 in SDR-21 PVC
16.1t�fV�1Z'C�$1NC f31t U$1Lit-: ee .. :a ACd^f00 MATERIAL
Company Name ' ` 7 FROM TO DIAMETERi THICKNESS
2.Well Construction Permit#:
S ft. ft. in.
List all applicable vrll corurmction permits(i.e.LIC'.Cotugv.State. Vartunce,etc.) ft. ft. in.
3.Well Use(check well use): t.7.1SC1tt EN SIZE,
THICKNE55 MATERIAL
FROM TO DIAMETER _SLOT
Water Supply Well: ft
Agricultural �MunicipaUPublic
dcntial Water Supply(single) ft ft.
Geothermal(Ncating/Cooling Supply) acs-
t
m
esidential Water SuDPly"(shared) tg:GVGUT �LITERLAL' EMPLACEMENT\ffTHUD g AMOt NT
lndustrial/Comntercial FROM TO
lrri-a[ion ft. it.
Nun-Water Supply°Well: ft. ft.
ORccovcry
Monitoring ff. ft.
injection Well:
Aquifer Recharge [3Groundwater Remediation 1gr5AND/GRA ELPACK:fsfa lkatrle EMPLACEMENT PIETHOD
O nIATERLAL
�$alintty Barrier T ier ft. -
Aquifer Storgge and Recovery
Aquifer Test oStom rwatcr Dra ft inage ft
ft.
Subsidence Control
Experimental Technology 20:. RILLING LOGtattacli ad 8onaksb
Cseotherrnal(Closed Loop)
Tracer FROM TO DESCRIPTION eolor.h nets solU'tOC6 tl a in size,CM)
Geothermal(Heatin Conlin Return) Other(explain under#21 RemarKS) Q ft. ft.
—XS 5 WelllD#
4.Date Well(s)Completed: ft. ft.
Sa.Well Location: ft. R.
$rn•s o ae- ft. ft
Facility/Owner Name Facility LD (if applicable)
1 ft. ft a
t 1
physica� �Adres;.cttd Zip 2I:ILEM1{S''
3� s��t.24sc3svz .
parcel Identification No.(PIN) , ,n.'Z 3--
County ^ t
. UI
5b.Latitude and longitude in degrees 4. i.
/minutes/seconds or decimal degrees: 22 Certi a
(ifwell field.one lat/lone is sufficient)
N � Date
SigtaturcufCcrtiticdWcllGm acturl
6.is(are)the well(s) Permanent orTempnrary
By igning this form.L here!.certifi!that the-ell(5)Iva,!were)constructed in actor ante
•.ith/SA NCAC 02C.0100 or I M NCAC 02C.0200 well Construction Standards and that u
Dwell: Yes Air No
7.IS this a repair t0 an exiStinr copy ofihis record has lice,provided to the well owner.
1(this is a repair•fill out knoem well construction in(nrtnation P explain the nanvc of rite 33.Site diagram or additional well details:
repair undta'ill remarks section err an the back (this fun,.
You may use the back of this page to provide additional well site details or well
S.For f;,eoprobe/DPT or Closed-Loop Geothermal Wells haling the same
constntction details. }'ou may also attach additional pages if necessary.
constntction,only 1 GW-1 is needed. Indicate TOTAL NUMBERofwelis SUBMITTAL INSTRUCTIONS
drilled:
LA —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: construction to the followin.':
Far multiple reelGc ICsr all deptkr ifdi(�ercnt j�rarnple-3/2�_011'and lC l00')
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 seater level it ahnve casing,ace"+"
11.Borehole diameter 6 /S (in.) 24b.For infection Wells: Inaddition to sending the form to the address in'_4a
above,also submit one copy of this form,within 30 days of completion of well
12.Well coostructioo method:
Air Rotary construction to the following:
(i.e.auger,rotary.cable.direct push,etc.) Division of Water Resources,Underground Injection Control Program,
1636 Dian Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: to
Method of test: Air Flow 24c.For V1'ater SDDDIV&Iniectio_n Wells: In addition to sending
the
da Si of
13a.Yield(gpm) the address(es) above: also subrnmW one co v of this form
Chlor Tabs t 1/2 Lhs completion of well construction to the county health department of the county'
13b.Disinfection type: Amount: where consructcd.
Form Ow-I North Carolina Department of Environmental Quality-Division of Water Resetlrces
Revised'_-'-'--_'Olo