GW1-2022-05649_Well Construction - GW1_20220610

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information: 7.77
Robert Teague a >{z
FROM TO T TOO DESCRrPTfO*• �
Well Contactor Name `, °' —
B &K Well Drilling Inc ft - t
NC Well'Contractor Certification Number "SOITE1i G zvG D[@!tt wetls''OKi# if
1 FROM I To DLIMETER TffiCK_N.TSS rL4TERIAL
2857-A 0 ft. ft. I S.)g in- SDR-21 PVC j
Company Namc Ib:il�tvEK'G,k511st6TLStNGI .eet8ez'tuadit eW400
— FROM TO I DIAMETER THICKNESS I MATERIAL I
2.Well Construction Permit :_ ) JJJ rt, fL i "
List all applicable well corutruction permits o.e.C7C.Comtrv,Stale.Variance,etc.)
ft. ft. in. '
3.Well Use(check well use): p;
Ii71SCitEF3t
W
ater Supply Well: FROM TO
DIAMETER �WTSIZE THICK�FSS MATERIAL
aivlunicipaJPublic fL
Geothermal Mcating/Cooling Supply) widcntial Water Suggiy(single) fL rt In
lndustriai/Commercral esiden ial Watet Supply(Shazed) i G1zQlJ
FROM TO t1LATERL4L ESiPLACES2ENT SO=THUD lv iMOi".�-IB ..
lrriaation ft. fL
lion-Water Supply Well: I
-Monitoring 13Recov ery'
injection Well:
Aquifer Recharge Groundwater Remediarsor. -1-4 SANINGRAVE1s4.9:UA fif:a bc�lel". .
�Saliniry Bamer FROM To
NLATEROLL EMPLACEMENT
Aquifer Storage and Recovery 1(ETHOD
fit. ft.
r3Aquifcr Tcst oStormwatcr Draina_c
Subsidence Control ft. ft
Experimental Technology >
CaeO[hermal(CIOSed Loop) Tracer Z&BRIIEITrGfOC attachaddtrienstsleeeisaTue vrocl t =nlnsac.ac)
FROM TO DESCRIPTION color 1 cs.
r-tGeothennal(Hearin Coolin Retunr) n Other(explain under#2l Remarks) ft. _;�S ft
L) u ell ID# ? ft.
4.Date Well(s)Completed: I
i
5a.Well Location:: fteVLC ,�
rt.
Facility/owner Name FacilirylDr(ifapp 1 e)
ft. ft.
Physical Address,City,and Zip -
Parcel ldentification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Cel'ti� I(i+f(yf4git�lan Pro-C&sswg Unit
(if well field•one ladlone is sufficient) /£M,,��--,,�-�-yy••�'On'^ DWID/L- -
Dats:
Sis.'Itatun:of Ccnificd Wclt Cno cum
6.is(are)the well(s)OPermanent or Temporary
By cigmng this form.there/v cert fy viral tine xrll/s)wnc tx ereJ corurnrcred in accordance
,•.ith 15A NCAC 02C.0100 ur 15.4 NC.4C 02C.0200 Well Curstrucaun StnnJarJs rind drat u
7.Is this a repair to an existing well: 13Yes or cops oft is reco,d has beer[provided.n the well ow:acr.
11'this is a repair,r1I011i knoxn well constrtction information a d t'.. lain the nauve oftitc
I epair undr r 421 rrnrarks section ur on the bark of this fibrin. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same constriction details. you may also attach additional pages if necessary.
construction,only 1 GW-I is needed. indicate TOTAL NUMBEROfwells SUBMITTAL INSTRUCTIONS
drilled: Lq
9.Total well depth below land surface: �(ft-) 249. For All Wells: Submit this form within 30 day of compleliou Of well
For multiple,s'Clls 1Lv all depths rfdlfjerent(,rmnp/r-3(it•?00'and 1@100') constriction to the following:
40 (ft) Division of Water Resources.Information Processing Unit,
10.Static water level below top of casiDg: 1617 Mail Service Center,Raleigh,NC 27699-1617
1/'1surer level is above casing,toe"+"
6 1/8 (in.) 24b.For infection Wells: In addition to sending the form to the address in 34a
11.Borehole diameter: above.also submit one copy Of this form within 30 day of completion Of well
Air Rotary constriction to the following:
12.Well construction method:
(i.e.auger,rosary.cable.direct pLL;U.etc.) Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
3 Method of test: Air Flow 24c.For Water SuDDIv&Infection Wells: L-i addition to sending the form to
132.Yield(gpm) the address(es) a�oi c, also submit one copy of this form vv'ithin 30 days of
Chlor Tabs 1 112 Lys cotnPletiou of well construcuou to he count}' health department of the county
Amount•
13b.Disinfection type: where constructed.
Rsed
North Carolina Department of Environmental Quality-Dixision of Water Resources
Form GR'-1ev 1_-21_-'Ol o
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