GW1-2022-05655_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD(GIB•-1)
1.Well Contractor Information:
Robert Teague 14-W=TT.RZoxr:! I
Nell Contractor Name
B& K Well Drilling Inc r.
L4 11�rjrr
NC Well Contractor Certification Number
2857-A FROM T{Ci' Dtt�t3TL� T=Cis—mac. Ka 2
rt. fL
Company Name 1&INNERCASL G�f3RTt i�Grl ietL ttcl beD}
2.Well Construction Permit#:� I FROM To T+Ic"KvES� M+rxa,-L
i.isr a[1 applicable well cmtsrmcdon permits(i.e.UIC.Coway,State.Yararee,etc-) ft. ft. in-
fL fi. in. .
3.Well Use(check well use):
Water SD R SCR€Et-
Supply Well:
i F
UN TO DIAMETER 1;WTSIZE 1 THICKNESS MAT ERIaL
Agricultural E)Mtmicipal/Public I! fL r- In
Geothermal(Hcatiny'Cooling Supply) Rcsidcncia!Water Supply(sin_ie) ft- j tL in. 1
Industrial/Commercial �[\Residential Water Stipp'%(shared) ' 18 GRf)ff
irrigation i FROM I TO I ?LtTERLA-L I EytPL%CE%M%-rN EMOD B,tMOCNT
Nun-Water Supply Well: tt. fL j
Monitoring InRecovery ft. ft.
Injection Well: ft.
Aquifer Recharge DGroundwater Remedi4ion
'<T9::S4:�#37GRh��i;1'4CK ftf, 'licable3 i
Aquifer Storage and Recovery [DSaliniry Barrier I FROM ' TO I EMPLACEME`1T METHOD
Aqui fcr Test [3Stormwatcr Drainage
ft. ft.
Experimental Technology [)Subsidence Control ft. tt.
Geothermal(Closed Loop) []Tracer 24.DRIlAJNGLQ .aygchaddr ioiia3sheetsi#t
F OPI TO DESCRIPTION valor.hard" tVroel.VM e- to S¢l,CoLl
Geothermal(Heating/Cooling Return) n0ther(explain under#21 Remarks) h t r
4.Date Weli(s)Comviete&�- 30-92 well ID# �L'^S it• � tt. r. � �
5a.Well!Location: lltLLYJ �
ln+�YZ lsS Yl\ 1�')1C hGZ-� Llp� .5OS f` ��-1 Cl 1� c
Facility/Owner Name Facility ID#(ifapplicable)
�h1 ���y11 ft. ft.
Physical Address.City.and Zip
JUN 1 0 2027
County Parcel identlflc Lion No.(?IN)
A'
5b.Latitude and longitude in degrees/minutes/secoOds or decimal degrees: D "rY"•+'
fif wdl field.one Iatllong is sufficient) 22.Certification:
N W
tsII:etm�tit C�^.tcu lt` .Cna3zct:>i Datc
6.is(are)the well(s)OPermanent or [3Temparary
gy vigring the lorr'. �r:err?:ca-:7i rra::re�rwo .a,!.crc/con rand in accordance
nirh.i s¢�'C-.3C;i�C. 32C.Cefi%t If'e(1 Curtorrucrun Standards and that u
7,is this a repair to an existing well: Yes at J Nc 0 o(4 NCAc�rd . -ems: <,s=s:o:1:.'..cif
i/this is a repair.fit[ow knoxn>+eG construction injnnnation ann "P in the nature o1;hc c
repair under#21 renrta-ks sm-trun ur un the bark of this orm. 23.Site diagram or additional well details:
S.For GeoprobeiDPT or Closed-Loop Geothermal Wells having the same You may use e back o_this page to provide additional well site details or well
construction,only 1 GW-I is needed. indicate TOTAL NUMBER ofwells
construction.detaiis. l ou ma}'also attach additional pages if necessary'.
drilled:—ed SUB1t[TTAL iNSTRUCTIONS
9.Total well depth below land surface: U S (ft-) 24a. For All Wells: Submit'this form within 30 days of completion of Weil
Fnr mulrip[e ire//c!iv a![de[>r!u i(diJ/"rren:r:_rarnp(e-.i!2'IUO'and�Cl filly construction to the following:
10.Static water level below top of casing:40 (ft-) Division of Water Resources.Information Processing Unit,
IJ%varel•level it abewe caving ute-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (in,) 24b.For Tniection 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 i.e.auger,rotary.cable.direct puslL etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLSONLY 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Iriiection Wells: In addition to sending the foum to
the address(es) above, also siubinit one copy of this form within 30 days of
13b.Disinfection ty Chlor Tabs Amount: 1 Ii2 Las comP letiou of well con;rrucnon'to the county health department of the county
pe:
where consnuctul-
Revised 2-22-2016
Form Gw-I North Carolina Department of Environmental Quality-Division of Water Resources