GW1-2022-05712_Well Construction - GW1_20220609

Pr..it Fo�n i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague IGiAiR:ZONF$
-.:
FROM! TO DE.SCRTPTTON
Nell Contractor Name c.L ft- 5 9 S ft I
B &K Well Drilling Inc
ft. ft-
NC Well Contractor Certification Number
15<OUTERCASING maift cased wells`QK1 iF
2857-A FROM TO DIAMETER I THICKNFSS NLATERIAL
p ft' ft 6 1B tn SDR 21 PVC
Company Namc
};6. 1tN'NERG'A.SI11tGf '1`U$1Ft(.-:: 3i a t:Losed-fD8' -•r
2.Well Construction Permit#: 13 Cl� FROM TO DIAMETER THICKNESS MATERIAL
��
List till applicable a�ell conut[vction pennies(i.a.U1C.Cowrty,Stole,Yurimtce,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: t.T:SC3IE€34
_ FROM TU DIANIE FR )WTCIZE THICKNESS MATERIALAgricultural E)Municipa✓Public ft ft in.
Goothennal(Reating/Cooling Supply) Residential Water Supply(single) ft ft to
Industrial/Commercial residential Water Supply(shared) I%.G12OtT.*
Irrigation FROM To NLIkTERLAL EM[PLACEMENTMETHOD g+MotTM-r
Nun-Water Supply Well: rc- ft
Monitoring []Recovery ft. ft.
injection Well:
ft, ft.
Aquifer Recharge Groundwater Remediation
.<l�t$tti4f>IG1t4V�t.$4C�$G€ Iicable .. , ....:
PlAquifer Storage and Recovery [3Saliniry Barrier FROM TO NLATERLAL EMPLACEMENT NlUHOD
Aquifer Test [3Stormwatcr Drainage ft. ft
QExperimenW Technology Subsidence Control fr- t[-
nGeothermal(Closed Loop) nTracer Z�i37i iEIYG1OG,fttachad 8oia1s1 8€.
Geothermal(Heatin Coolin Return) Other(explain under>21 Remarks) FRONt TO DESCRIPTION rnbr h dness soiVroe6n °rain size-M�)
_ ,
4.Date Well(s)Completed:-\�� Well ID# ft. (� ft'
5a.Well Location: G tt. ®Set
ft.
tt.
C_.c, e: I LCl
Facility/Owner Name �— Facili(y LD4iifaoplicable)
U--(,C:K ,t��(�f ft. ft. a
Physical Address,City,and Zip ft- ft
\ 2�.REDiARItS
G
County Parcel Identification No.(PIN) fassaw-ng
of
n i ru. O(3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.CertjtJ[6.Is(are)the well(s)oPermanent or Temporary S4�We 1 CnntracU>i Datc
liti signing[his jontr,7 herein;car[fy,that the avlks)mac(acre)coasrntered in accordance
7.Is this a repair to an existing well: [)Yes or No n ith 1 SA NCAC 02C.0100 ur LiA-VC,4C 01C.0200 well Cunsauctiun Strtndords and that n
!(this is a repair,rill ores known well ennstntction infonnation an .rplain the native ofihe copy'aflhis record has been provided'to the well osvaer.
repair undt, '21 renttaks section or on the bark of this form.
23.Site diagram or additional well details.
S.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
consmlction,only 1 GW-I is needed. Indicate TOTAL NUMBER ofwells constniction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
1
9.Total well depth below land surface: \O (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well .
Far tnutriple wells lea all depths ildif(erent finatnple-3r900'and 2[t 100� construction to the following:
10.Static water level below top of casing:45 (ft) Division of Water Resources,Information Processing Unit.
lj svate,•level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For iniection Wells: In addition to Sending the form to the address in 24a
Air Rotary above.also submit one copy of"Ibis form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct pus1L etc.)
Division of Water Resources,underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) d1 V Method of test: Air Flow 24c-For Water Supply&Infection Wells: In addition to sending the form to
the addresses) aJov'e, also submit one copy of this form within 30 days of
13b.Disinfection type:
Chlor Tabs Amount: P 1 1/2 Lbs completion of well construction to the county health department of the county
,
Where constructed-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised'_-2'--2016