GW1-2022-05726_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORI3�Gf L1
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1,Well Contractor Information:
f to W,-T{71Ex�__" t til-c�2.r?TiC1`�
Robert Teague FROM
Well Contractor Name
B &K Well Drilling Inc5 ft
_ RCAS,ts � € . ±iaYr�taL
NC well Contractor Cenification Num ���
bertvtETZ.R i T>� 1
rRo�t I To
2857-A p ft. j ft- ( ta-
�� "� TRIMNESS "i +ta;lT3ai
Company Name w`r/ =� - 30E0, FRONKn�RC DIAMETER
f0 FROnI TO � I
ft. fL in.
2.Well Constructio Perm e_
List«ll applicable Hell tottstruction permits(i.e.UIC,Coungv,State.Vur mtce,eu.l ft. fL in.
3.Well Use(check well use): f?> REFN FRONT TO DIAMETER "�I.OT SIZE THICK�fS •rarauat
1
Water Supply Well: ft. ft. in. '
Agricultural OlViunicipaI/Public
Rcsidcntial Water Supply(single) ft ft
m 1
Gcothcnnal(Hcating/Cooling Supply)
� r-
esidential Wate:Su-,piv(shared) 18:6R0U•t EMPLACEMF\TNwrHODL
lndustrial/Commercial FRO>t TO nLsrExLu 1*to T
irrigation i ft. ft.
Non-Water Supply Well: ft. i ft.
Monitoring ORecocery
-
ft. I ft. l
injection Well: 1
Groundwater Remediation 5 �gAy gACR(rt f?
Aquifer Recharge NLA7I� EAL4L EMPLACEME�TAttTtFrID
TO
Aquifer Stor9ge and Recovery Salinity Barrier FRO?! ft. ft. 1
['Aquifer Test [3Stormwatcr Drainage ft. I
Subsidence Control ueces3
Experimental Technology -
race 28.BRi1 Li
Geothermal(Closed Loop) [� FRo,I To DESCRlPT10A br. arQnass so(Urock is c ra,"
p3T r TO size.Steer
GeothetTnal(HeatinqjCooling Re 10ther(ex lain under 421 Remarks) I ft. /s ft. +�
ft, 7 ft. ✓ ! t �,
4.Date Well(s)Completed- 1 a- Well ID# -
I. t. r
.„ slz�l zz Is
Sa.Well�Location:�•�� ft. ft.
t i i flJ"d W�s�rtl� ft. ft.
Facility/Owner Name ` Faciliry lD (if applicable) ft. fL
ft. ft.
Physical Address,City,and Zip Zi R£1w1t�RKS Z.
Parcel identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutesiseconds or decimal degrees: 22 Certificati
(if well field,one ladlong is sufficient)
W
IN /1 / c_�-� - 7
Sissta�tic •cif Grntre�i<rr
Date
6.ls(are)the well(s) Permanent or Temporary
By signing this form.i herelry eerrifi'that the a xrllls}was(were)confiner red in accordance
'.rith 1�,4':CdC 02C.0l00 err/SA NCAC 0K.0200 Well Cunstructiun Standards anJ;hat a
Yes or o cope c(tris retard has beer,provided to the kill owner.
7.Is this a repair to an existing well: P,a ?
a
If'this is a repair,fill out known well construction inj'nrmarion a d e.plain the nature of the 23.Site diagram or additional well details:
repair under#21 ED
n<nrurA�section or ern the back u(rhis funn. o�n.a,,
You may'use the back of this page to pro
additional well sltOls or well
construction details. 1'ou may also attach additional p�}N1 222
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same ,J`J lv
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled: fir`� 9 Uni:
� �mn"li of well
ft) 24a. For All Wells: Submit this form witAR 'day" r ,66y�t.JJ��
9.Total well depth below land surface: construction to the following:
For multiple Welk list all drlydts i(difterent(ermnp/e-3(ic700'and?@100')
10.Static water level below top of casing: Processing Unit,
40 (ft.) Division of Water Resources,Information
1617 Mail Service Center,Raleigh,NC 27699-1617
[(water level is ai,ove casing,use"+ in 24a
11.Borehole diameter- 6 1/8 (in.) 24b.For iniection Wells: It addition to sending the formof completion to the sof well
above•also submit one copy'!of this form within 30 days
Air Rotary construction to the following:
12.Well construction method:
(i.e.auger,rotary,cable.direct push,ate•) Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: Air Flow 24c.For Water SunDly&Ilniection Wells: In addition to sendnug the form to
13a.Yield(gpm) the address(es) above, also Isubtmt one copy of this form within 30 days of
Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type: wnccrc consnuctcil
! Revised 2-22-2016
North Carolina Depamnent of Environmental Quality-Division of Water Resources
Form CW-1
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