GW1-2022-05635_Well Construction - GW1_20220610

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WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only:
1.Well Contractor Information:
Robert Teague
FROM TO DESCRIPTTON
Well Contractor Name FROM
C 51L L CS'
B&K Well Drilling Inc / '^
rt. h.
NC We11 Contractor Cerification Number ,.alfllti-rased vrE11s E't&i>3i�It ii <;15:011'FE1tCP;5ING
2857-A FROM To DfaNfETER THIctiPTiSs KATERIAL
0 fL ft 61/8 In- SDR-21 PVC
Company Name
11 / _ _16ti1i��'E&'F;�S31�iG4It'Fx1BfFFG:, matictose<1-toe`_ ,.; , ,..::
2.Well Construction Permit#:�I t vZC; �C�� �G, FROM TO DIAMETER I THICKNESS j MATERIAL
List all applicable well construction permits(i.a UIC,Comrry.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Il7i:,Sf3iE£h.
Water Supply Well: FROM TO DIAMETER SWT SIZE THICKNESS MATERIAL
r-lAgricultural E)Muoicipa✓Public ft- ft. in.
Geothermal(Hcating/Cooling Supply) Rcsidcniial Water Supply(single) ft- ft. m
Bindustrial/Commercial residential Water Supply(shared)
IfBiz�RCJ13T..>.
Irrigation FROM To NLATERL&L EMPLACENgN-r NMTHOD&AMOUNT
Non-Water Supply Well: ft- fL
[JiMonitoring DRecov'ery ft. ft.
Injection Well:
ft. rt.
1711,Aquifer Recharge [)(;roundwater Remediation
14::StLiYIHGi2 A*rEL,f'4G faf. Iicablel
Aquifer Storage and Recovery [3Saliniry Barrier FROM TO NLATERLAL EMPLACEMENT NLETHnD
MIAquifcr Tpst [3Stormwatcr Drainage ft. ft.
r'lExperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) TracerR 2& 1RIIf13GIOC.xtfacls:ae3lehsla€
Geothermal(Heatin Coolin Return) Other(explain under t21 Remarks) FROM To DESCRIPTION icotor.hsrdnc%s.solyrock to oratn size,act
r1- ft. A
4.Date Well(s)Complet.6-L'`�a Well ID# ft. ft- (`C
5a.Well Location:
Facility/Owner Same Facifiry LD#(ifapplicable)
Physical Address,City,and Zip ft. ft
..
l2�'i:REDi9R14,S
County Parcel Identification No.(PIN)
Prxc 1:9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J '
(ifwell field•one]at/long is sufficient) 22.CertljlE
N W
6.Is(are)the well(s)OPermanent or OTemporary Sigttatury of CcrtifieJ Wt Contractor Datc
ay signing this form.I herely.v certify that the ue/Jfs)were twcre)consiruaed in accordance
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7.Is this a repair to an existing well: 13Yes or No pith i?A NCAC 02C.0100 or li4,NCAC O2C.0200 Well Construction Stundar iy and that a
Ifthis is a repair,fill ota brow well ennsintction information and rplain the native ofthe copy ofthis reenrd has heen provided to the well owner.
repair under#21 remarks section or on the bark of this form.
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
construction,only IG -I is needed. Indicate TOTAL NUMBER of wells construction derails. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6, (If-) 24a. For All Wells: Submit this form within 30 days of completion of well .
Fnr multiply u-ells 1W all delnths ifdii fereni(:sample-30V'00'and?@l001 constntction to the following:
10.Static water level below top of casing:40 (ft-) Division of Water Resources,Information Processing Unit,
If wafer level it above caving use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For iniection 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
1
132.Yield(gpm) Method of test- Air Flow 24c-For Water Supply&iniection Wells: In addition to sending the form to
the address(es) above, also subrriit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 112 Los completion of well con arucrioi to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revered 3-32-2016