GW1-2022-05646_Well Construction - GW1_20220610

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague
Well Contractor Name DESCRIPTION
FROM TO
B&K Well Drilling Inc l�
NC Well Contractor Certification Number t l Q
15.:t1i FEIZCASI`IG
2857-A FROM TO DLIMETER THICKNESS MATERIAL
0 tt. ft. 61/8 in• SDR-21 PVC
Company Name - - -.
� ft. T`ot.J� 1b1NNEftG"�SI�fG.43R'II}SfAIG eethexm:il!ttose+i-too
Z.Well Construction POrmit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cotutruction permits(i.e.UIC,C'omgv.State.Variance,etc.) ft. i
n.
3.Well Use(check well use): ft. ft. in,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public it. ft. in.
Geothermal(Heating/Cooling Supply) csidondal Water Supply(single) ft. ft to
lndustriaUCommercial Residential Water Supply(shared) RD
Irrigation
FROM TO K&TERLAL EMPLACEMENT METHOD 8 AMOUNT
Non-Water Supply Well: ft. ft.
MonitoringRecovery ft. ft.
Injection Well:
k it.
Aquifer Recharge E)Ciroundwater Remediation
d9s:SeiiY13TG1�.Y`Et,f'4G�(tt. lce6te >; ;
lAquifer Storage and Recovery DSaliniry Barrier FROM TO NLATERL4L I EMPLACEMENT METHOD
AquifcT Tcst [3Stormwatcr Drainage ft. ft.
PExperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer Z :F/RILEIAtj.tG.attachaddii�obaf slceetsalets i3
FROM TO DESCRIPTION color,na as,soillroel.t\ main size.etc)
Geothermal(Heating/Cooling C.00lin Return) Other(explain under#21 Remarks) ft. rt.
4.Date Well(s)Completed:L� l S ell ID# tt. R.
tt. tt.
a.Well Location:
ft. it.
1 Facility/Owner Name �` �,,_/1 ,+a�/FacifiEyy IDti(ifapplicable) - H
`� 4' 2 W el TAU 11� S4Vf �. Mr c4yerr�I ft. ft.
Physical Address,City,and Zip ft. ft. 0
County Parcel Identification No.(PIN) uy t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lont:is sufficient) 22.Certi ation:
N W ' /�"^ ^
6.Is(are)the well(s) %Permanent or OTemporary ign;turc of Certified Wcl1 Come r Datc p�
By signing this form,1 herehv certify that the xr/lfs)wac(were)comrructed in accordance
7.Is this a repair to an existing well: [3Yes or allo ,ith 1 SA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
ifthis is a repair,ill out kitowm well construction information d plain the nature of the cop)'of this record has been prnvided to the well owner.
repair und(a-921 renua•4;section or on the bark of this farm.
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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: .4 ^ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well .
Fm multiple sse/A 1w all depths ifdii ferent(trample-3r:200'and 2 a 1001 construction t0 the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If soarer lei el is above casing;ore•'+.. 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
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 submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well consi action'P.the county health department of the county
where consnueced.
e
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016