GW1-2022-07342_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague
FROM I TO DESCRTPTION
Well Contractor Name t L( !J(lft. 3 i
B &K Well Drilling Inc ft. ft•
CidG! ! 4
NC Well Contractor Certification Number
T5;OU'FER�GA�S71aIG :mdttrcasedisvelh
2857-A FROM O DLIMETER THICKNESS M.4TERtAL
0 ft. ft, c 118 bL SDR-21 PVC
Company Namc
-:1 CANNER m�#:dosed.
2.Well Construction Permit# FROM I To DIAMETER THICKNESS MATERIAL
List all applicable well cocantccion permits li.a UIC.County.State.Variance,etc.) ft. ft.
ft. ft. r^•
3.Well Use(check well use):
f7:SCREEM1;:.:.
Water Supply Well:
PPY FROM TU DIAMETER SWTGIZE THICKNESS I M.4TER(AL
Agricultural 13Municipal/Public ft ft. in.
Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) g fL in.
l ed• -' W 1 sear -:.,..;.......
IDdustnaUComnierc,tal Resldenual ester Supply( )
iaB.GRUIIT><»>::_::;<>:>:>'>:>:;a:.<>z:>:::>:;>s.:>:;:»>s>::;»::>:;::>:<:;:><;::<:>:>i>i>i>i::>:::>s>s::>:::>>:
1m ation FROM TO MATE RLAL EMPLACEMENT METHOD&AMOUNT
Nun-Water Supply Well: ft. ft. IA
Monitoring r3Recovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge E)Groundwater Remedigtion
Aquifer Stordge and Recovery Salinity Barrier FROM I TO ,NLkTERLkL EMPLACEME`tT NIETHOD
AquifcrTcst [)StormwatcrDrainage ft. ft.
Experimental Technology Subsidence Control ft. tt.
Geothermal(Closed Loop) [3Tracer 28:BRiiEIP1G#:QG atisch.add9ti6iiaksbeets=if: : ..
FROM TO DESCRIPTION rntor ht as so,Urocl. ansm s¢e,ere)
Geothermal(Heatingt/Coolin Return Other(explain under�21 Remarks) R ft
ti
4.Date wells)Completed tom Well ID# ft. r
tt. tt.
5a.Well Location:
ft. (t. ..,.- Y
� r-s l-l�i P yL�B Se
Facili
ty/Owner Name Facility 1D�(ifapplicable) r�6 fit. s tt. ox
ft.
f ✓ 1 'I�C'Ca?+�CJh tt- rp A
Physical Address,City-and Zip ft.�— "
ED
21::REi4iARK$ , wx
,
County Parcel identification No.iPTN) .l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (f14fJt �ttC l f.
(ifwelt ficid,one lat/Iong is sufficient) 22.Certificatio pt UClnOG
7
ificJ w G+ntrecu+r D'
6.1s(are)the well(s)OPermanent or [)Temporary t b amn of Cpn
By signing this fibrin.i herehy-certify char the xrllls)+vac(x,crc)coastntctcd in acco-dance
7.Is this a repair to an existing well: nYes or MSG frith 1 SA NCAC 01C.0100 or 1 iA NCAC OIC.0200 well Construction Standards and that u
1/'this is a repair,fill our Anom)well construction information and r plain the native of the copy of this record has been prnvideil to the xrll boner.
repair tinder a.!rentai-A-s setiion ar on the,bark of this form. 23.Site diagram or additional well details:
8.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
constriction details. You may also attach additional pages if necessary.
constniction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
Far multiple urlls 1w all delmltr ifdii ferew(kranple-3(2200'and 2@1001 CAIIStntetiOn t0 the followm^:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
lf+.aret•le.•el is ahes•e casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (in,) 24b.For fniection Wells: In'addition to sending the form to the address in 34a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: constntcuon 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
132.Yield(gpm)_ '.Method of test: Air Flow 24c.For Water Supply&luiection wells: In addition to sending the form to
the address(es) above, also submit one cops' of this form within 30 days of
13b.Disinfection type: Amount.
Chlor Tabs 1 112 fibs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-1016