GW1-2022-07341_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague aa�1tAlRzoivfw
FROM TO DESCRIPTION
Well Contractor Name
1 So ft. ft. �
B&K Well Drilling Inc rt. t.
• 1. L
NC Well Contractor Certification Number `1`Si:OT FBR!GAS1fitGi fer:'oitttfi2c svel .OR'Lt` t tf'
2857-A FROM To DL-0 ETER TInCKNT:55 +LaTERLAL
0 ft. ft. 6±18 I SDR-21. PVC
Company Name
16;:1h'1VEK: f>:flR'FUStIcFG:' of tl
Z.Well Construction Permit#' FROM TO DIAMETER THICKNESS I M.ATERtAL
-ist all applicable xrfl caarnrcr.'on permits fi.�UIC.(:csr.}•,Stme.Yarimrc'e,etr.l ft. ft. in. i ,
,n
3.Well Use(check well use): fL tt.
Water Supply I I'7:St3YE£h
FROM TO DIAMETER I SLOT SIZE I THICKNESS MATM AL
Agricultural []MunicipaYPublic ft. ft. i9•
Genthcnnal(HcatinglCooling Supply) Pcsidcntial Water Supply(single) ft fa in.
j
Industrial/Commercial D idential Water Supply(shared)
irri ation FROM I To aLJ.TERL'.. EMPLACE: :NTMETSOD3.t Ofti3 t
Nun-Water Supply Well: ft. fL
Monitoring 1311,ccovcry
Injection Well:
Aquifer Recharge ©Groundwater Remedigtion
1$.:�AiYiNGMA:YELi'4CK:(if flciiblc}..'•,.::':'.:".::;`'?7. .
Aquifer Stor2ge and Recovery [3$alinity Barrier FROM TO 1UTERUL EMPLACEMLNT METHOD
�AquifcrTest [3StormwatcrDrainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer T$EItTLLdtVG ads h.itddiitoiia}sheeta-$
FROM I TO DESCRIPTION eolor.hard ova iVrocl. grain sac.ete.l
Geothermal(Heating/Cooling Return) rJOther(explain under t21 Remarks) ft. ft. -
4.Date Well(s)Completed: 7- 2 Well TD# S ft. d
Sa.Well Location: t S rt.
S V'�� 3 f_S
Faciliitty/0 nee 1% Faeijli�ty �(ifapplicable) ft. ft-
3/ 76 l Q/ !S S l re' ' ✓� /� - ft. ft.
ft. ft.
Ph sisal Address.City,and Zip
Si'ItEI►i4RlS6: ;: Tarr;:: .. ;.
r U►-u
County Parcel Tdenti5cation\o.(PiN)
IG 0 8 7077
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat.'lonc is sufficient) 22. -fcation:
(ntCfl1T31tD 1 Pf:>LNau(itf'tJ UfSk
N W D�N>�IBOG 7 .7 -
$t�.ntat of C�nificd well Cnn for Datc
6.Is(are)the well(s)SPermanent or [3Temporan
'Jr.signing this farm•?herein;certify that the xr11Gs1 was txrreJ corrsmrcred in accordance
7,is this a repair to an existing well: nYes or No Tvith i SA PiCAC 01C.0100 or 114-'C.4C 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knoxn well ennstruetion infnnnar,'on and xplain tRc nawe ofthr =opt oftnis rerord it-s hcrn prn;;dcd,tn the xpii orrrc%.
repair under#2.I remarks section or un tine bark of ihis./o m. 23.Site diagram or additional well details
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use t«e back of this page to provide additional well site details or well
conMiction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction:details. You may also attach additional pages if necessary.
drilled: SUBN11Tr.AL IN'STRUCTiONS
9.Total well depth below land surface: (ft) 24a_ For All Reds: Submit this form within 30 days of completion of well
For multiple n•e/k luf all depths rfdiffereni(sample-gr,700'and 2@100') constntcrion to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,information Processing Unit,
ff water level tc abeve casing,use— 1617 Mail Service
Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: 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: constntction to the following:
(i.e.auger.rotary.cable.direct push etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELL`ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Lt Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Chlor Tabs Amount r t12 Lbs completion of well consnucdou to the county health department of the county
where constructed.
Form GV'-i
North Carolina Department of Environmental Quality-Division or Water Reso irces Revised'--22-'Dlo