GW1-2022-05641_Well Construction - GW1_20220610

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague a! ViAlElFoIVES
FROM TO DESCRIPTION
Well Contractor Name Jft.
B &K Well Drilling Inc ft. l lJ{t
NC Well Contractor Certification Number -
'TSOL'1'Eg'GitS74�tG1 ::triad cased yells`EfK L11`»'Xt'ii.
2857-A I FROM TO DLIMETER TEEICICNESS DL>TEEZ
o ft- ft- I 51/8 m- SDR-21 PVC
I
Company Namc T6:1lNNER'CA-Sllt6:4R Flli3 eetheim3kdosed lvo' 1
J FROM TO DIAMETER THICKNESS MATERIAL.
2,Well Construction Permit#:
Its(nil applicable x ell cottrrruction permits(La L%lC.�oanv.Stare.Variance,Ole.) t[. ft m.
ft.
3.Well Use(check well use):
Water Supply Well: FROM TU DIAhI ETER )WT SIZE THICKNESS MATERIAL
Agricultural [31%lunicipaJPublic it ft. in.
r—IGcothcrtnal(Hcating%Cooling Supply) MLSidential Water Supply(single)
Ind ustriaUComniercial R idential Water Supply(shared) i&:GROIjf i
irriga[iUn FROM I TO �L1TER]>I EMpIACEMENTD�THUDB.L�IOC�T I
?Von-Water Supply Well:
Monitorial riRecovery h. ft.
injection Well: I ft I ft-
Aquifer Recharge Groundwater Remediation
L9:.SFLaV13 GIt4� i':aiC Ctfa lieabte3:,....
Aquifer Storage and Recovery DSaliniry Barrier FROM I TO EMPLACEMENT IErdAD
:3Aquifcr Test [)Stormwaccr Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 26:BRTi.LJKIG:LOG attachaddiaesalslree(sa€flecess
FKOM 70 DESCRIPTION color hardne<s soiVroek t� °rain size.etc.)
Geothermal(Heatin Coolin Return) Other(ex lain under#21 Remarks) ft. G tt. " - , t'-,
ft.:
4.Date Well(s)Completed` 2-U-')- 'Well ID#
ft. ft.
5a.Well Location:
LA �\\ s ` � �/i�1 ft. ft.
rYe
Facility/OwnerNamz Fuciliry IDr fifaoplicabiz) 5
4— ft. ft.
Physical Address,City.and Zip
` I'2i;S2Ei4ZARKS %: ,
CountyParcel ldentificatlon No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lonc is sufficient) 22.Certificati9tP:
Stgnetu:c of C::rificd aic
6.Is(are)the well(s)opermanent or [)TemporaryWclt Contractor D
8v signing this(ornt. 1 herelm certify that rho xr//(s)1vad fx.ere)emurracrea in accoidmrcc
7,is this a repair to an existing well: [)Yes or EXNo girth I.4R YCAC 02C.0100 ur 1.RINCAC 01C.0100 well Cunstrucriun Standards"I'd that a
Ifthis is a repair,rll ma,btoxn well ennslneetioa infnnnatial rd,. lainlhc nature o/t)re
cope'of this rec—d has been provided to the Well o.cur.
I epair undo-#21 renua-ks se.ctiun wr un III,,bark of lhis furor. 23-Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Log Geothermal Wells having the same You may use the back of thislpage to provide additional well site details or well
P constniction details. you may also attach additional pages ifnecessary.
constniction,only I C;W-1 is needed. indicate TOTAL NUMBER of wells
drilled: J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of compietiou of well
Fnr multiple wells lar all depths ifdlJferent(tranple-3!m-'00'and 2 ai 00� constniction to the following:
10.Static water level below top of casing:
40 (ft.) Division of Water Resources,Information Processing Unit,
if water level t<above casing,use"�' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For infection 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,rosary.cable.direct paslL eta)
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 Supply&In i iection Wells: In addition to sending the form to
13a.Yield(gpm) ` �5 the addresses) a'oove, also(submit one cops' of this form within 30 days of
Chlor Tabs 1/2 Lbs completion of well construction to the count}' health department of the county
13b"Disinfection type: Amount:
where consrvucd.
Form GR'-I North Carolina Department of En�ironmentai Quality-Division of Water Resources
Reused 2-23.2016