GW1-2022-07340_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD (GW-D For Internal Use Only:
1.Well Contractor Information:
Robert Teague
I4.:VPATERzoi� ;
Well Contractor Name FROM TO DESCRIPTION
B&K Well Drilling Inc ft.
©ft.
I rr. rc.
NC Well Contactor Certification Number
>1 :01}'FER:CA'S7NG€ar'uiettrca3edsvelfs.OR'is11�IFit i[;: <<;>:f<::?>:;::; :jj; ::i
2857-A FROM To DL4METER I THICKWIESS M1LaTERUL
Company Namc 0 ft. ft' 61/8 m SDR-21 PVC
` 16��11�NfiJZ:G.#,StAfGUR:'F:IJ$1CIC: �'' oral%closed-lo .
2.Well Construction Permit#: C� ��1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits/r.�LjIC.t..omtty.Store.Yarimtce,etc.) i ft. ft. in.
3.Well Use(check well use): I tt. ' ft. in.
Water Supply Well: F.
FROM TU DIAi11 ETER SWTCI7.E THICKNESS MATERIAL
Agricultural 13Municipal/Public fL ft. in.
Geothermal 04catingiCouling Supply) csidcn[ial Water Supply(Single)
ff. ft. in. .
Industrial/CO mmeroial Residential Water Supply(shared)
aB GR
l ter Supply Well:
Non-Water FBONI To %LkTERL4L I ENIFLnCEMENT METHOD&MfOt'NT
fc. fi.
Monitoring DRecovery ft. ft.
injection Weil:
:)Aquifer Recharge Groundwater Remediaion
Aquifer Stor2ge and Recovery OSaliniry Balmer FROM TO I BL4TER141 EMPLACEisa;0IENTDIECHOD:l`1>'> i
PAquifer Tcst DStormwaccr Drainage ft• ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
26BRT1LI$Gl !attaeli:nddit- f-ihetn4tf
Geothermal(HeatingiCooling Return) r30ther(ex lain under r21 Remarks)J
FROM ToI DESCRIPTION color,herdnes&roillroel emin sae ete.l!
ft. ft. y
4.Date Well(s)Completed: Well ID# 3 ft~ ft.
a.Well Location: R. rt.
rP I is on ft.
/Facilityf/Ow`nerNanie Facility 113�"(ifapplicable) S -ft• t•
n 1e) LSn /"-�`1 12 C`
Ph ical Address.City.and Zip ft. ft.
Ur 1Lg..
z1
County Parcel Tdenti6arion Na lPIN) AUG 0 S 2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one ladlont is sufficient) 22.Certi'ida' i D%JVQ/80G
NV W l�Jl / C
6.Is(are)the well(s)oPermanent or Temporary Signatvrc ufCcmficd C.t�vactor Dal.
Bv'sigrrng tkCr form,]lrereiry cerff tear the%rllw wu(were)comtrueted in accordance
7.Is this a repair to an existing well: Yes oN-
23.NO !rith LrR^:CAC 02C.0100 ur 19R NC.4C:02C.0200 Well Construction Standards rind that a
!/this is a repa r,fill out Frown well canitntctiat infnnnall. xplain the nature ofree copy ofthis rernrd ilas been provided In the xril ou.-.er.
repair under colt remai-A-s section or un the bark ofthis furtn Site diagram or additional well details:
8.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
constriction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9,Total well depth ow land surface:For multiple u�el%c!Lv all drprlcv if (ft-) 24a. For All Wells: Submit this form within 30 days of completion of Weil
d�erra[(::rumple-J!2"•_rUO'and_'CI fi0')
construction to the folloivin;:
10.Static water level below top of casing:40 (�
_ ) Division of}Water Resources,Information Processing Unit
I/ gate level cr above caving,ate 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For Tniection Wells: In addition to striding the form to the address in 24a
12.Well construction method Air Rotary above. also submit one copy of this form within 30 days of completion of well
(i.e.auger.rosary•cable,direct push,eta)
constntcaor,to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) IL4 Method of test: Air Flow 24c. For Water SDODIV&Iniection'lWells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above, also submit one'copy of this form within 30 days of
13b.Disinfection type: Amount_ completion of well construcnon to thle county health department of the county
where consuucu 1.
Form G1;'-i North Carolina Department of Emircnmen tai eP Quality-Division of Water Resources 'i, Revised 2-22-2016