GW1-2022-05652_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information: k
l
Robert Teague a :gnTRlc.zol+lFs. ..
FRODI TO DE.SCRTPTTON
Well Contractor Name eq C ft 1 C 0 IL
B &K Well Drilling Inc l I J l:
re. rt.
NC Nell Contractor Certification Number
15:<f)1)CEiLGASII`TG tiistt ea4ed wells:Q&i31 if: liea4 '
2857-A FROM J O DIAMETER THICKNESS MATERIAL
D f4 / L 6 1/8' In- SDR 21 PVC
Company Namc
�" ' - 16:=11`1YER G�S'41k6 f11t'E1FSf:t!FG:'eet�essmatitlose8-ioii ,
2.Well Construction Permit#• I- W� 2,n3 7 S FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable w'till construction permits fi.e.UIC.Comny.State,Variance,etc.) it. ft. in.
3•Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SWTCIZE THICKNESS MATERIAL
'Agricultural �Municipa✓Public Fc R. in.
Geothermal(Reating/Cooling Supply) oRtaidcrltial Water Supply(single) ft ft- in.
Blndusuial/CommercialResidential Watcr SuPP1v
(shared) F%i�itUbT xx X.. > .
irri ation FROM To aL&TER7AL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring DRecovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:Si31YD1GitlVELi'4Fit€a );table
Aquifer Stor9ge and Recovery 05aliniry Barrier FROM TO hLATERL4L EMPLACEMENT METHOD
nAquifcr Tcst [3Stormwatcr Drainatrc
QExperimental Technology Subsidence Control
QGeothermal(Closed Loop) Tracer %Z 13RII.I 1iG.1 OC:attaclt.a3daetdalsaf
Geothermal(Heatin Cocilin Return) rJOther(es lain under T21 Remarks) FRo.I
ft. To DESCRIPTION Dolor na nos,so uroalc tr _tat size.cta)
4.Date Well(s)Completed 3 - Well ID# \ (, 4' > 1.
5a.Well Location: ft. ft.
it. ft.
Facility/Owner Name ` [ Facility tD#(ifapplicable) ft. ft.
L / 7 Q ft. ft. L.+ _1 3
S -� �'��Q h Qom_ La n )� fJ'Z' c7 V i rt. rt.
Physical Address,City.and Zip _.
23 [tfiE4RKS.
�7so3
1— :
County Parcel identification No.IPM) "� '
VA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ! OG
(ifwcll field,one lat/lont is sufficient) 22.Certification:
��
/ --s- J -
6.1s(are)the well(s)OPermanent or Temporary Signalurc of CLnificd Contractor Datc
ty signing this fibrin.1 herelry cert!*y that the xell(s)was rwerc)consrrucred in accordance
7.Is this a repair to an existing well: [3Yes or "raNn ".ith 1.5A NCAC 02C.0100 or 1i4 NC.4C 02C.0200 Well Construction Standards and that u
ffthis is a repair,ill our knower well construction information and ee..plain the nature ofthc copy'ofthis record has been provided to the well owmer.
repair under#21 remarks section or on the back of ihisffunn.
23.Site diagram or additional well details:
8.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 I GW-1 is needed. indicate TOTAL NUN BER-ofwells construction details. You may also attach additional pages ifnecessary.
drilled: w -- /\ J� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y (ft-) 24a. For All Wells: Submit this form within 30 days of completiou of well .
Fne-an duple wells list all depths rfdii fereni(i ratnple-3r!200'and 2Q/001 construction t0 the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
/*+rater level ie oil+ore caving,else"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (in.) 24b.For infection Wells: In addition to sending the form to the address in 34a
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
Q
13a-Yield(gpm) J d Method of test: Air Flow 24c_For Water SunDIV&Infection Wells: In addition to sending the form to
the address(es) above, also subnut one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1)2 Lbs completion of well construcuou to the county health department of the county
where constructed. o
Form GW-I North Carolina Department of Environmentat Quality-Division of Water Resources Rev6ed2-22-2016