GW1-2022-07285_Well Construction - GW1_20220809

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague :.....>:::;;:: i::;::>::;:>;;::<:::::;<:>.:>;»::>;>,<::>::;::<:<:>•::.;> :.<::>;»:>:<:::>:>':
FROM TO DESCRTPTTON
Well Contractor Name
B &K Well Drilling Inc z�rt. r rt 6
NC well Contractor Certification Number
2857-A FROM I To DIAMETER THICKNESS KATERiAL
p ft. ft- 6116 m- SDR-21 PVC
Company Nara I4'1NIVSRGSF1�lOR ElFB3FtG
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable--ell constrwLion permits(i.a UIC.Couny.State.Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. In
E€.3k : ::: :";;i>? FSii:ii: i..:,:. < i:; c......:+:i ' 2 : :;i;_;ii;_
Water Su Well: R
11,,�� ..... ........
PP'7 FROM TO DIAMETER SWTSIZE THICKNESS MATERIAL
cultural ElMunicipal/Public ft ft in.
Geothermal(Hcating/Cooling Supply) E)Residcrltial Water Supply(single) ft in.
... Shared ::............::.::::::.....:::::.�: :::.�::. ::.:�.:
lndustnaUComnterc,ral Resldenual Water Supply(Shared)
:i:;:::�::::::>:�::;':"::Y;:>:>:%i:�?:�::::;::;<:;>;:::>:>:;<::::i:Y•:::.'1::;:;;::::>::::�;::::`:i:`>:
irrigation
FROM TO DLL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it. is
Monitoring ®Recovery ft. ft.
injection Well:
Aquifer Recharge Groundwater Remedippon
...14,S •.:....:........:._:.:.:.:....
Aquifer Stor9ge and Recovery Salinity Barrier FROpI TO ALATERL4L EMPLACEMENT METHOD
r3Aquifcr Test []Stormwatcr Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) TracerB 78:BRrf:1>INss:1�Q::att¢ch:aioiiokalieets ::;: ::
Geothermal(Heatin Cooling Return) Other(explain under 21 Remarks] FROM To PSCRIPTION MID, near aoiV e-;;in
sac,ere)
rt. S rt G
4.Date Well(s)Completed ';�Z-� We11ID# $ S ft. R. 41 yd
" Sa.Well Location: cs Q
rL ft.
090CILN V�IlrY11-1
Facility/Owner Name Facility IDS(ifapplicable) ft. ft.
l lA r-m
l� .�`----
Physical Address,City.aad Zip
........:.. ..
County Parcel identification No.(PiN)
511h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 22.Certificatian- q�
N W
6.is(are)the well(s)ox Permanent or Temporary gipaturc of Ccnificd W' ct ontraor Dal.
,� By signing th&form.1 hereby certify that the xrll(s)was Were)consmcted in accordance
7.Is this a repair to an existing well: Dyes or [ _No frith 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,ill out known well canstruction intonation and explain the nature ofthe copy ofthis recur d has been provided to the well owner.
repair under 921 remarks section or on the bark of this form. 23.Site diagram or additional well details:
S.For Geo 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit This form within 30 days of completion of well
Fat'multiple ne/A liv all depths ifdii ferent l�?ranple-3,_5_00'and 2C1001 construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
If.v-arer level is aNwe casing;use '+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Tniection 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.etc.)
Division of Water Resources,,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,INC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form 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 construction to the county health department of the county
where constructed.
Form GW 1
North Carolina Department of Environmental Quality-Division of V.'ater Resources Revised 2-22-2016