GW1-2022-05558_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague "14}IA"It
FROM I TO DESCRrPTTON
Well Contractor Name Eft, fL
B&K Well Drilling Inc ft. ft.
• I
NC Well Contractor Certification Number
t5:0UTE1t:GAS1NG iiintfressed<svef E3t3'i3t if. ,::
2857-A FROM To DIAMETER THICK74ESS MATERIAL
0 ft. ft- 6118 1- SDR-21 PVC
Company NamcRxx
1.6.>INNER:CAMNG OR FU$fNG at:tlosed-loo
2.Well Construction Permit#• FROM TO DIAMETER - THICKNESS MATERIAL
List all applicable well construction permits fi.e.UIC.Corotty.Sidle.Variance,etc.) ft. ft. m.
3.Well Use(check well use): ft, fL in.
J 7zSttE€N
Water SD I Well:
PPY FROM I TO DIAMETER SWTSIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) fL ft• in.
:::..:.....::
Residential Water Supply(shared)
In dustn:)Industrial/Commercial cal P Y
�y� ;:>.rs:»:i:x2ar>:z
1W.9
irrigation
FROM I TO ...DLI.TERL EMPLACEMENT NIETHOD&AMOUNT
Nun-Water Supply Well: ft. rt.
Monitoring ORecovery ft. fr.
injection Well: ft. tt.
Aquifer Recharge Groundwater Remedigtion
..
;;;;;:;:;-::;::
Aquifer Stordge and Recovery [3Salinity Barrier FROM TO NUTERLAL EMPLACEMENT DIETHOD
Aquifer Test [3Stormwatcr Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
... ..:.
Geothermal(Closed Loop) Tracer 2�:'i11tIIL1A1G1:Q�: ttachadditioiie3dlxeb3E
FROM TO DESCRIPTION Tor,ha nos.tdVnxk in size.etc)
Geothermal(Heating/CoolingReturn) Other(es lain under#21 Remarks) ft ft
1
4.Date Well(s)Completed-5—I ''1— ell ID# ft. ft.
tt. tt.Ina
So.Well Location:
K r��,e, t�r-t ft. ft.
Facility/Owner Name Facility tWI(iEapplicable)
rt. ft.
y
ft. it.
75
ft. ft. E tE p
Pcal Address.City.and Zip
1r n t.a l 0 ZO22
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Imam a-
(if well field,one la/long is sufficient) 22.Certif 0 D%VQIBOG
N W
Si aturc of CurtificJ Wcll Contrac or Date
6.ls(are)the well(s)OPermaneot or Temporary -
b1-signing this form.1 herelry certify that the urllls)sva,farrc)consrnictcd in accordance
7.is this a repair to an existing well Yes or o pith 1.5A NCAC 02C.0100 or I.iA NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,I'll out brown well constriction informs[).... nd plain the native of the copygfthis record has been provided to the xrl(oumer.
rclwir under k71 renuu-ks section or on the.back of this.funn. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constructiou,only I GW-I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
IV
\ S
9.Total well depth below land surface: 3 C (ft-) 24a. For All Weds: Submit this form within 30 days of completiotl of well
For multiple ur//.s list all depths i(dlf/erent/:trample-3@ 200'and 2@1001 construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
if water level is above casing,use'•+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For injection Wells: in addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(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
13a.Yield(gpm) Method of rest: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subtait one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-23-2016