GW1-2022-05634_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
I
Robert Teague 4V.AL'TMR7— 'r
FRONT TO DESCRrPTION
Well Contractor Name ft. ft.
-
B&K Well Drilling Inc rt, ft.
NC Well Contractor Certification Number
1'Sz4UGEWGA51 atrafEr.'caseri;tielts::©R ' . i[ ;::y>;;o;•:::.;;::' ..
ZSS7-A FRONT TO DLIMETER THICI4VESS MATERIAL
0 ft. 51/8 in- SDR-21 PVC
Company Name ^ 1'6:;1l�IVEKGiS#hIG:URlf81 at:e[oud-loo'
2.Well Construction Permit#• Ov FROM TO DIAMETER THICKNESS MATERIAL
list all applicabic Nell construction permits/i.e.UIC.county, role.Variance,etc.)
f[. ft. 1O
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft ft. 'in.
Geothermal(Hcating/Cooling Supply) WSidcntial Water Supply(single) ft tL in.
IadustriaUCotunereial DRC51dCIlu al Water Supply
(
shaye d
)
ciB:Gtt[fi3T <:
irrigation FRONT TO SLI.TERL EFIPLACEMNT DEETHOD&.UHOLtN'[.
ft. ft
Nun-Water Supply Well:
Monitoring 0Recovery
Injection Well: ft. ft.
)Aquifer Recharge � u Grondwater Remedi�ion -
.. tl
Aquifer Stor2ge and Recovery Salinity Barrier FRONT TO NUT EMPLACEMENT DIEfHOD
Aquifer Tcst [)Stormwatcr Drainage ft. ft.
Experimental Technology Subsidence Control ft. tc.
Geothermal(Closed Loop) OTracer 2&:3fItIIsEI1�1G:ii:Q `'attYcli:a3d#ioidsiEaecesd' :a:;;>:
FROM TO DESCRIPTION color, ness,miVtroelc r h,sac.e[a)
EGeothermal(Heating/Cooling R^^e��tuu�m) nother(explain under#21 Remarks) 6 ft ft.
4.Date W ell(s)Complet
��- 1'�- Well ID# 5 ft. t
f[. ft.
" 5a.Well Location:
_II fL ft.
Facili /Owaa Name 4acility 1Da(if applicable) ft.
0 S 1 ft. ft. t': ' =o- E I-a f
CA CS 01 Physical Address,City.and Zip - -
>:SI.REb4:4R1tS,
Li r\c ) h�n
County Parcelldentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22.Corti
N
� �p
Datu
6.Is(are)the well(s) Permanent or/ OTempnrary Si,ataturc of Ccrificd W cll >ntri ctor
d Bl signing this form.1 herelry certify that the xrll!sl w2r Iwcre)eonsrntercd in accordance
7.15 this a repair to an existing well es ortd
o with 1.SA h'C4C 01C.01t10 ur Ii.4 NC.4C 01C.0200 well Construction Standards and that a
IfthL4 is a repair,'ll ota known Nell canstntctt n to onnauion plain the nature of the
cop}'of this record has been provided to due cell olvixr.
repair under#21 renur/a se nun ur un 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
constniction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
constriction details. You may also attach additional pages if necessary.
drilled: 1 - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: CK -5 (ft) 24a. For All Weds• Submit this form within 30 days of completion Of well
For multiple wells 1w all drptkv ifdi(g"erent(example-3(2,200 and 2@1001 construction to the follolving:
10.Static water level below top of casing:
40 (ft) Division of Water Resources,Information Processing Unit.
if%weer level iv above caving,ace..+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in,) 24b.For Infection Wells: In addition to scnding 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:
li.e.auger,roury,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
Method of test• Air Flow 24c.For Water Suably&Tniection Wells: In addition to rending the fats to
13a.Yield(gpm) the address(es) above, also 'submit one copy of this form within 30 days of
Chlor Tabs Amount: 1 112 Lbs completion of well con;t!cdon department to the county health deparent of the county
13b.Disinfection type: where constu=d.
I
Farm CW-1 North Carolina Department of Environmentai Quality'-Division of water Resources
Revised 2-22-201 ti