GW1-2022-07349_Well Construction - GW1_20220808

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague wwkTERRZONE.
FROM TO .. DF-SCRUTTOH
Well Contractor Name
B&K Well Drilling Inc
NC Well Contractor Certification Number
15 OifFEIZCASIAIG: m+itfi cased srelis'.k1R 'T i!F)A iE' r
2857-A FROM TO DL>METER 1 THICtv1y'E5S MaTEAIAL
0 ft. ft. 5118 M- SOR-21 PVC
Company Namt
J� (/— 16::11WEWCASING:O RITU$t1YG.'eetTjetmai closed=ke
2.Well Construction Permit i#: ti;L (Vn .
FROM TO DIAMETER THICKNESS M>TERIAL
i.ist rill applicable Well consm(crion permits lie-UIC.County.State.Variance,cu.) j ft.
ft.
3.Well Use(check well use):
Water Supply J:7::SCitE£h
ppy Well: FROM I TO DIAMETER yWT$IZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. 1°=
Geothermal(HcatingiCooling Supply) RcsidcnEia[Water Supply(single) ft
Industrial/Commercial Residential Water Supply(Shared)
irrioatiun FRWi To MATERLAll EMPLACF-MENTDEETHOD&AMOUT
Nun-Water Supply Well: ft. ft
NIanitorim, []Recovery ft. ft.
injection Well:
Aquifer Recharge [3C;roundwarer Remedig(ion
SANDIGRAVELP:kGK
Aquifer Stor2ge and Recovery Salinity Barrier FROM I TO )UTERLAL EMPLACEMENT METHOD
�Aquifcr Tcst [3Stormwatcr Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 2g ERML1NGLW.7 attachi"iiinalrsUeets:ifnece5s
FROM 11TO DESCRIPTION c-olur to as."Wi,ock ..e._ to sae,etc.)
Geothermal(Heatine/Cooling Return) nOther(explain under=21 Remarks) ft. ft.
1
4.Date Well(s)Completed.'11-:2�L Well w# - ft. eft.
c ft.` ft.
5a.Well Location: `_ r
f
T-'n L 7�Ir� �. i \ r. ft. FE
t ti C�<
Facdiry)Owner Name Facility LD=(ifanplicablz)
fr. ft.
101 3, Sk)k�4 ?� SO� [ tt�r c! �y\C�'g i ft. i ft. �
Physical Address.City,and Zip ft. ft. 1
� * 4� ',YT n `21_REiIiFiRKS (fr#CiPflal'1t�a t L- � "
County
�T Parcel identification No.(Pm)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one latllone is sufficient) 22.Certification:
Natz
Signature of Certified Wc11 Contra> fr. — Datc
6.ls(are)the well(s)oPermanent or OTempnrary ,
Br signing this form.I herein,certil}'Aar the wrlhr)aav(were)comm'cied in accordance
7,is this a repair to an existing well: DYes or MAO +i ith 1 SA NCAC 02C.0100 ur h.A NC.dC 02C.0200 well Cum,rrucriun Sutndards and that a
IIfthht is a repair,ill out known well constriction information a r. lain the nature of the colas of Iris record lens been prnvr'ded in the x ell outer.
repair ander 921 remarks sectivn ur un the back of this farm c 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
P p constntction details. You may also attach additional pages ifnecessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells
drilled: A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !/ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For mahiple mr/Lc lice all deluhs ifdii ferenr(;xample-3(a-200'and 2@/00) construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
If water 1"el it aM ve casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Tniection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy ofi this form within 30 days of completion of well
12.Well construction method: consuitcuon to the following:
I i.e.auger.rotary,cable.direct puslL ctc.) I
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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
13b.Disinfection type- Chlor Tabs Amount: t tf2 Lbs completion of well construction, to the county health department of the county
wbert:consuuctul.
i
Revised 2-22-2016
Form GN'-1 North Carolina Department of Environmentai Quality-Division of Water Resources
I