GW1-2022-07284_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD(GW-1) i For Internal Use Only:
1.We ontractor Information:
Robert Teague
FROM TO DE,SCRTPTTON
aWell Contractor Name ft. t. E
B&K Well Drilling Inc it rt
NC Well Contractor Certification Number '
" ,OFfFER:Gti57.
2857-A FROM TO DIAMETER MCKMS MATERIAL
0 ft. ft. 61/8 i to SOR-21 PVC
Company Natnc
I4%1l lYSAG S#N OR FFJ$Il1G aYd
2.Well Construction Permit#' FROM TO DIAMETER - THICKNESS MATERIAL
L (i
ist all applicable well construction permits -e UIC.Cotarty,Store.I arimrce,etc.) ft. ft in ft
3.Well Use(check well use): fL ft. in.
3 ' isi:'oi2:ii>:i::;:'i2:i'isi'ii:i;ii`lit:isi:;:'i:: i::::>i?F?t>''ii<isisi>:>: zi:ii:<:::`?:!i;i;?i:;ii
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
Agricultural E)Muoicipal/Public ft ft. ii,.
Geothermal(Hcating/Cooling Supply) [3Rcsidcndal Water Supply(single) ft ft in.
h
Induindustrial/CommercialResldenual Water Supply(shared)
.....
inn atiUn
FROM I TO NLITERLAL EMPLACEMENT N=OD&AMOCTNT
Non-Water Supply Well: rt. rL
Monitoring EIRecovcry tt. tVED
Injection Well:
Aquifer Recharge [3Groundwater RemediVion
_.,. Aquifer Stor-age and Recovery [3Salinity Barrier FROM TO I EMPLACEMEJITDIETHOD
Aquifer Test [3Stormwata Drainage ft' ( 4ri13b►E3>1 Pmc!!® Until
Experimental Technology Subsidence Control ft. ft. LAIVI.YULP13
Geothermal(Closed Loop) Tracer 269BR)3 f>TsYGaJc3.�'attscksddrtioniil Aeecv :<:»>:<: <
FROM TO DESCRIPTION mlor, -csL Wtlmck t pe.-rein she,etc.)
Geothermal(Heatin Coolie Realm) Other(explain under�2!Remarks) ft «
4.Date Well(s)Completed a`� Well ID# ft. ft.
ft. ft.
f5�a.Well Location:
12
Facility/Owner Nam, Facility IDh(ifapplicable) o ft• ft-
102C cene�' ��� Cbi i( Koo flo sP ft. ft.
ft. tt.
Physical Address.City.and Zip
County Parcel identification No.iPiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
{if well field,one ladlone is sufficient) 22.Certitieatiioo -
N W
6.Is(are)the well(s)O%Permanent or OTemporary ignaturc ofCcnifrcd well C or; Date
By signing this/orin,1 herelry certify that the xrllfsl was/were)constructed in accordance
7.Is this a repair to an existing well: [)Yes or yS�No '.ith 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cunsrructiun Standards and that u
If this is a repair,ill out known well construction information an explain the nature of the copy of this retard has been provided to the well ourur.
repair under#21 renturks section or on the back of this.furn. 23.Site diagram or additional well details:
S.For Gen robe/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
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecassary.
drilled: A
SUBNiITfAL INSTRUCTIONS
9.Total well depth below land surface: lJ (ft-) 24a. For All Wets: Submit this form within 30 days of completion of well
For multiple urlls list all depths if&fferent(arannple-360-200 and 2@1001 construction to the.following:
10.Static water level below top of casing:40 M) Division of Water Resources,Information Processing Unit,
If wares level it above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For infection Wens: 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.e.auger.rotary,cable,direct push.eta)
Division of Water Resources,!Undergronnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the fox-in to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type Chlor Tabs Amount 1 1/2 Lbs completion of well con;trucnon to doe count}'health department of the county
where consuucccd.
Form GV`-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 016