GW1-2022-07352_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague
l4:�i'ATER ZONES ;.; .
FROM TO I DESCRrPTSON
Well Contractor Name ft.
B&K Well Drilling Inc
NC well Contractor Certification Number
i'i3�O@TGER�G1SItYGi `:oielftcssediaelts`;0[tial+Fh.Rit,, .lieab ,:r<:;;;>>,>t:;:.<>. :;
2857-A FROM TO DUIMETER' THICKNESS MATERIAL
0 ft. ft. ;.18 SDR-21 PVC
Company Name
>P �•� Ib.ai�NERfit511�tt:OR`•Fl)B31!iG:
#: ( (-IJ� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit
list all applicable well constriction Pernntr ILL' UIC.County,State.Variance,etc.) t[, fL
ft. r[, in.
3.Well Use(check well use):
Wafer Supply Well: FR5rvI TQ DIAMETER SWT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public tL ft, in.
Geothermal(Heating Cooling Supply) Residential Water Supply(Single) ft rL in.
Industrial/Commercial Res' u'al Water Sup
ply(s)are i
)
. FROM TO NUTERrAL EMPLACE:MUNT161ETHOD&..1MOtrNT
Irrigation
ft.Non-Water Supply'Well: fc.
Monitoring DRecovcTy ft. ft.
Injection Well.
Aquifer Recharge [3Groundwater Remediyion - -
>S9:5AiVfl7GR4w.FLP4CK'Gf:.., ;:iai>s>::s..
Aquifer Stor2ge and Recovery Salinity Barrier FROM TO �LATERLUL EMPLACEMLvrr METHOD
r3AquifcrTcst 0StotmwatcrDrainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 28DRT#:t7A1GL '> 'oai33>aes'[
FRolrl TO DESCRIPTION color,Nrdnesi"IVrV lc arum site,etc)
Geothermal(Heatine/Coolin Return Other(explain under Remarks) ft . ftL LA .
4.Date Well(s)Complete —3- Well 1D# LA N
ft. 3L ft. 1
���4Fac
Well Location:
ry/Owner Natne Facili ME(if licable)
7 ft. ft. _
ft. ft.
Physical Address.City,and Zip
P� Z1 RE11iiRKS '`~
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.-
(if well field,one lat/long is sufficient) 22.Certift
S11,T,aIurc of Ccetificd Wcll C,mvac
6.ls(are)the well(s)oPermanent or [:)Temporary
!h cigring this form,I herelry certify that the rril!s)was tucrel constructed t'n accordance
7.is this a repair to an existing well: Yes or'On rith l5A,vCaC 01C.O100,,r h.A NClC u2C.OlGO Well CVnstruct un Standards and that a
if this is a repair.fill out known well construction infonnation d t cplain the nature p1 the copy of this record has been provided to the well ouvcr.
repafr tinder 22l rema-ks s;m-ion or Vn the hark of thiofann. 23.Site diagram or additional well details:
8.For Geo robe/DPT or Closed-boo Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction derails. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: Q SUBMITTAL INSTRUCTIONS
elow
9.Total well depth land surface: 3 Q� (rt-) 24a. For All Weds: Submit this form within 30 days of completion of well
Fat-multiple u•ellt 14v all dr/+ria i(dii ferent(:xatnple-3!&200'and?C/o0� COIIStriCtiOII t0 the f011Ovving:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If•,vater level it above caring,mve"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For iniection 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: construction to the following:
(i.e.auger.rotary,cabie,direct puslt etc.)
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 q-pe: Chlor Tabs Amount- t 112 Lbs completion of well construction�to the count}' health department of the county
where constructed. j
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resourc!{es Revised 3-22-016