GW1-2022-05654_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD (GW-PLOW
For internal Use Only:
1.Well Contractor Information:
Robert Teague
FROM TO
Well Contractor Name `
B &K Well Drilling Inc ft. 7L;? ft-
Number L
tf:...
NC Well Contractor Cettificaciun 15 01f CER:G2i514`rG iiitittrc(i :velh';f)1x'Ltl!fBR 1ATERIAL
FROM TO DLIMETER •I'giCIS7ESS
2857-A D ft• 6� ft. 6 718 in. SOR-21 PVC
cttlseda
Company Natnc lb_1fi IVfiR:G'vSll!fG.OICTUStNGi MATERIAL
FROM TO
ft.
DIAMETER THICKNESS
`` in2•Well Construction Permit#: �� 1
List ein applicable xrll cortstrtection perms Me-L7C.(;amrry,Stare.Variance,cur.) ftfr ft in
3.Well Use(check well use): MATERIAL
METER
Water Supply Well: FRonI TU DIA )WT CIZE THICKNESS
Agricultural 0Municipal/Public
ft ft in.
Supply(si
Residential Waterngle t ft in.
Geothermal(Hcating/CoolingSopply) ' ) f
d
bare or-
u s )
S D Water �^:��1L�T3'f:?i%$'3:�.:i:;iyi`::;^;ii�%�>::; i:E� �i<' ;�.'iii:ii;:i::i _:�:?^�T80
lndusuiailCommercial Residential W Supply( 8.:G O nL�TERL+I EhIPLnCEAgtrT n�
FROM TO
lrriaation ft. ft.
Nuo-Water Supply Well: ft. ft.
Monitoring rlRecovery
ft.
Injection Well:
ft.
[3Grouudwater RemediVion
Aquifer Recharge r1Yl::w)IG1RA:V, #',4C11i lfc� ::: ;<:
O NUTERLAL EMPLaCEMEviPtETHOD
T
Aquifer Stor9ge and Recovery [3Saliniry FROM Barrier ft
tc.
Aquifer Test StotTnwaccr Drainage
Experimental Technology Subsidence Control
ft. ft
[)Tracer 3S BRiif itiachad+ftfij na.)ree+sitceceSa to sac.ctal
G [
Geothermal(Closed Loop) ) FROM TO E.cCRIPTION color s.pa so,Uroek ..
TRYY��Geothermal(Ileati Conlin Return) Other(ex lain under#21 Remarks) ft• _ �tt.
21 Well •
4.Date Well(s)Complete We
d�Q-- it r� _ t• !
5a.Well Location, i ft S fc•
M r C L1Catl 1 # ft. ft.
Facility/Owner Name Facility iD-u(ifapplicable)
N,
icol Address.City,and p
Phys' >2i31tEi►iA�R[{S:::n.;:»?i:;:;>::c;>y:
L "r
County — Parcel llantificanon No.(P1N) t rj q
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certif
(if well ficlo.one lat/long is sufficient)
' taturc of 0.•ttificd WA Con ctur
Date
6.Is(are)the we
Silp
s..
lls) permanent or �Tempnrary gv signing IN,form.I herelry tear(}•that the xrlift)wra txere)rnn entered in accordance
•r nith I SA NC-4C 02C.0/00 ur I LA NC.4C 02C.0200 Well Construction Stundanls and that u
1.is this a repair to an existing well: [3Yes or n copy-of this reenrdhas hccn provided to the uell owner.
lfrthis is a repair.(ill tna broxrr well conttr,+cuon infnnnadon d plain the nature o(the 23.Site diagram or additional well details'
repair tinder 921 renturks se stun ur on the hark ajrhis(urn. .
f this page to provide additional well site details or well
you may use the back o
if necessary.
S.For t;,eoprobe/DPT or Closed-Loop Geothermal Wells staving the same
construction details. you may also attach additional pages
constntetion,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells SUBMITTAL INSTRUCTIONS
drilled: of com letiou of well
9.Total w e o
ell depth bw land surface: 1 ` (ft) 24a. For All Weds: Subnric this form within 30 days P
Fm-multiple trolls!iv all depths i(dij(erenr r::rarnple-3!g'UD'an _(�10U? construction to the following:
40 (ft.) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
f(uwrer lece/it above casing,vse..+•
For Tniection We113: In addition to sending the form to the address in_
diameter: 6 1/8 (in.) 24b. ell
11.Borehole
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
Air Rotary construction to the following:
(i.e.auger.rotary.cable•direct pttslL arc-) Division of Water Resources,Underground injection Control Program,
1636 Mail!Service Center,Raleigh.NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
l !&Injection Wells: In addition to so ithn the form to
Air Flow 24c-For Water Su
132.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
Method of test
Chloe Tabs Amount:
112 Lbs completion of well con>tnicdon to the count}' health department of the count}
13b.Disinfection type: whcrc COnSnVeted.
1 Revised 2-2-1-2016
North Carolina Department Or Envinnmental Quality-Division of water Resources
Form GP•'-1