GW1-2022-03969_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(QW-1)
For internal Use Only:
1.Well Contractor Information: - s
t�WAl!EB ZOr�&'
Robert Teague FROI%1 TO DESCRIPTION
Well Contractor Name
B &K Well Drilling Inc
NC Well Contractor Certification Number 15'UtSCE1tCASiNG: iiititt+cased stalls ;0[HICM S
FROM TO DIAMETER I.- TffiCIStES MATERIAL
ft. ft. 611a in, SOR-21 PVC
28rJ7-Ps p
16<:LNIYERG51NGfliRItF:UBtNG te('- at.ClUSedtbb MATERIAL
Company Name FROM TO ft. DIAMETER' THICKNESS
r y ft. •
2.Well Construction Permit#: tc'
r.isf all applicable Well co»strucdon permits OX. LI C.Counrv.State.Yanmtue,etc.) tt ft. ;in. .,
3.Well Use(check well use): 13:SGRE�.
FROM •r•U DIAMETER SWTSIZE THICKNESS MATERIAL
Water Supply Well: ft. ft. in.
_Agricultural �MunicipaUPublie
in Coolin Supply) , Residential Water Supply(single) tt rL
m.
cat g «<:>;»;<::;:»:;:>:;:3i>:>:a:'<:>: 2>:
Gwthcnnal(H g/
Residential Water Supply(shared) I8;4RQLtT tn[>RLAI EMPLACEMENT 41-L nH 1 B.AMORN7
IndustriaUCommercial FRONI To
Irrioation
Nun-Water Supply Well: ft. ft.
ORecocery
Monitoring
injection Well:
Aquifer Recharge [3GrcundwaterRemediation ly;S ggy p4GK ► ► gatpy�ctntEYrntETHOD
FROM To NLATERLAL
Salinity Barrier fi.
Aquifer Storage and Recover}' ft.
Aquifer Tcst 3Starmwatcr Drainage
Experimental Technology Subsidence Control
ft ft
2&DRILEdI1G It)G ttecli addtYtErriitl<s3eets ilia to stzc—I��yyTracer FROM 70 DESCRIPTION color. rdnemsolVtockts
Geothermal(Closed Loop) 11
Geothermal(.Hearin Coolin Return)
ether(explain under#21 Remarks) tt, it
fc. �TL
4.Date Well(s)Completed: Well ID# ft I.
5a.Well Location: I ft. ft.
ft. s
r+--� Facility lDr(if applicable)
Facility/Owner Name {t• ft.
ft. 02�
Physical Address.City.and Zip
� Parcel Identification No.(PIN)
t.t .lisro"li I�Pa (:��iCdtitr.7 Uld�
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 12 Cer Ica n: _ 1
(if well field,one ladlong is sufficien()
N e �+
Date
Stpiatur .emfrcd ell Contractor,
c o
6.is(ore)the well(s)oPermanent or Temporary
gt'signing this,lorm.I herein;certi}i'th the wrl//.t)wac(w•cre)constructed in accordance
o i7h 15A A`C.AC O2C.0100 ur 154 NC.4C 01C.0200 well Cunsrructiun Strrndtrrds and that n
7.is this a repair to an existing well: [Dyes or No co ofthis record has heen provided to the urll owner.
1('rhis is a repair,i'll our known well construction information an raplain the na[ure Ql the 23.Site diagram or additional well details:
repair under=11 nrntarla section ur an the hark ufihis.funn.
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-Iisneeded. indicate TOTAL N UMBER ofwells SUBI\1ITfALINSTRUCTIONS
drilled:
(ft) 24a. For All wens: Submit this form within 30 days of completion of well
al well depth below land surface:
9.Tot face: constniction to the following:
Fnr multiple nrllr liar all depths i(dii event(e_rn/nple-3, 'an _@100')
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
tf,s'aret'level it ahm•e casing,tise"'+•
I I.Borehole diameter- 6 118 (in.) 24b.For{niection 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 well
12.Well construction method:
Air Rotary construction to the following:
I i.e.auger,rotary,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
a Method of test: Air Flow 24c.For Water Supply&injection wells: In addition to sending the fats to
13a Yield(gem} y of this form vyttltia 30 days of
the address(ts) above, also submrt one cop-
y Tabs Amount•
1 112 Lbs I completion of well construction to the county health department of the county
lib.Disinfection type: whcrc cons:luctccl.
Revised 2-32-20 16
Form GW-I North Carolina Department of Emirenmental Quality'-Division of Water Resources