GW1-2022-05668_Well Construction - GW1_20220608

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague
to::`val ztir
i FROM TO DHSCRIMON
Well Contractor Name C rt. I
B & K Well Drilling Inc J ft• rt•
NC Well Contractor Certification Number
15i01) R'CASING:tsi>inoifi cased sells ©R'L Rif:
2857-A FRo.t To DLAMETER Trnclt�Ess I }L4TERIAL
0 ft- ft. 5•/g in- SDR-21, PVC
Company Name 0 y,..0 2 Z
\ / G e ) 61b::1hIVSR'G�iS21`sOOIi'F(i831'IG' mat:closed-foe
2.Well Construction Permit#: l 17 ) J / t� FROM ro DIA�1 ETER THICKSESS MATERIAL
ft. in. � i {
list all applicable well construction permits/i.e.UIC.Cowry.State.Yararce,eu.) ft. t
fr. ft. in.
3.Well Use(check well use):
Water Supply Well: Pii:SC1iE£ly
PQ FRUni TU =, -rFiWT51ZE I THICK\ESS MATERIAL
Agricultural Municipal/Public it_. Geothermal(Hcating/Cooling Supply) Rciidcn6al Water Supply(single) fL
lndustnaUComntereral �Resldenual Water SuDP-: (shazetl) a%';GR0131' >:;. •,
Irrigation I FROM TO NLiTERL ESfpLACE1ghT METHOD&AMOUNT
Nun-Water Supply Well: I ft. ft.
Monitoring DRecovery ft. ft.
injection Well. it. ft.
Aquifer Recharge DC;rcundwater RemediVion
19c:$A!\f31GIt4Y$LPACKfif' 11Etib1el
Aquifer Storage and Recovery DSahnity Barrier I FRO?I I TO -LUTERLU EMPLACEMENT METHOD
i
Aquifer Test [3StcrmwaccrDrainage ft. ft.
[Experimental Technology Subsidence Control ft. 8-
Geothermal(Closed Loop) DTracer 28F3127I5IIHGLQ attach'adfioiia}slaee .:ifpeceSs
fROar 1 TO 0E.SCR1PTIOy color rdness,sorLroel:n mam sac tt�)
Geothermal(Heating/Cooling Return) r1l0ther(explain under t21 Remarks) ft rt a
4.Date Well(s)Cornpl¢ted,5-'/ 3— �Z Well iD# 7
ft'
ft'
Sa.Well Location: ft. ft. �) So
ft. ft.
I SS G 0,C-.S a ` t
Facility/Owner Name Facility iD=(ifapp!icable) I `
ft.
,1 it.
Physical Address.City,and Zip ft.
t Zi::R�rYI:ARKS ;;
(. i �C, - ►(tin InOG
County Parcel TdentiRcittion No.(PIN) s
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lonc is sufficient) 22.Certiftc�tion:
Date
6.!s(are)the well(s)�Permanent or Temporary 5 1111dtUrU Uf CcrtifiCd Wclt Cn aCWT
By'signing this farm.I herelry certify that the xr/lls)was!were)coasrntcrcd in accorda:cr
7.is this a repair to an existing well: DYes or E Nn with 1.5A NCAC 02C.0100 ur 1S.A A'C.dC o2C.02W well Curistrucriun Standards and that a
lf'this is repair,ill out known well entrstntction information aAd'-''ee plain the native ofth.' cop}'afteis mrord has peer,provided to the xrll ouRCr.
repair trader�21 retntvks section ur ern the hark of this funn. , 7-3.Site diagram or additional well details:
8.For Geo robe/DPT or Closed-Loop Geothermal Wells having the same You may use he back of this page to provide additional well site details or well
Q P construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
IV 19.Total well depth below land surface: 6� !ft-> Zda. For All Wails Submit,this form within 30 days of completion of well
Fnr multiple nr/ls list all deptls ifdiJfrrenr{:trample-3g.200•and 2C100' construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources.Information Processing Unit,
Ifwarer level is ahnre casing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 23b.For Tniection Wells: in addition to sanding the form to the address in 21a
Air Rotary above. also submit one copy of this form within 30 days of completion of well
12.Well construction method: constniceon 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 tbnn within 30 days of
P
13b.Disinfection type:
Chlor Tabs Amount: t 1/2 Los com letiou of well con�trucnon to the county health department of the county
where constructed.
Form OW-! North Carolina Department of Environmental Quality-Division of Water Rzsources
Revised 2.22-2016
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