GW1-2022-07355_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague a4:WAr�itzolr - X.
FROM TO DESCRIPTION
Well Contractor Name
ft. L)
B &K Well Drilling Inc rt. ft-
NC Well Contractor Certification Number ' '
150(TF`BitGAS7t`tG: ;afattr'c
2857-A FROM TO DLIMETER THICKNESS MATERIAL
0 ft.Co ft. 5118 it SDR 21 PVC
Company Name
'f�U t6.>lI�NER`C 457111GUR El1BtAM tAetmat:eltiCKNEv
2.Well Construction Permit#: r FROM TO DIAMETER THICKNESS MATERIat
list all applicable well construction permits/i.e U1C..Cotagv,Store.Variance,etc.) ft. fc. to
3.Well Use(check well use): ft. ft. In.
W
irrigation ater Supply Well: FROMTU DIAaI.TER SWTSIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) ft. in.
I (shared)
IadustnaUComnterLtal Rrsldenual Water Supply
. FROM TO aL1TERLiL EMPLACEMENT DfETHOD&AMOUNT
Nun-Water Supply Well: tc
Monitoring [3Recovery• ft. h.
Injection Well:
Aquifer Recharge [3Groundwater RemediVion
ilx}::'S1t�#}ICrlZaik�'1>:)a!!�`7"Q� :;o>:;::::•:::>:o-::;•:;>ro.::;:r>:;:::::::o>::::a:.
Aquifer Stor2ge and Recovery Dsalinity Barrier FROM TO NLATERUL EMPLACEMENT METHOD
Aquifer Test [3StorMWater Drainage it. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop)
Tracer 28:BR'[i:III!1G LQ.r:9ftIIClaamtH1a37REt54� '
FROM TO DESCRIPTION rnbr hardneIs. Vroek matn sae,etc.)
Geothermal(Hearin Conlin Return) Other(explain under#21 Remarks) rt- tt.
4.Date W'ell(s)Complstedkk�� Well ID#
QS ft.
` 5a.Well Location
, ` - j� { / �i{ �/�t�
lY�_t 7X A A�4 t l)! Y ` V r 1 k b e )) rL
Facility/Owner Name T— Facility lD�(ifapplicable) ft. ft.
H CIS �/� 7C l�l1d`( 1 C l Cl f C 6111 [
rt. ft.
Physical Address.City.and Zip
C at t��l��r nc I
County Parcelldentifieation No.IPTN) iPtinw
IO krV ''r3OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
fifwcll field,one Iatllong is sufficient) 22.Certifiea"
N Wr -
tsgtatun:of Certified Well Cn actor Date
6.is(are)the well(s)I Permanent or Temporary
By signing this form.I hereiry certify that the wrWs)was(wet•e)constructed in accordance
7.is this a repair to an existing well: 0Yes or ONo with 15A NCAC 02C.0160 w 1 SA NC"9C 02C.0200 Well Construction Standards and that a
11•thia is a repair,ill our known well construction infannatian ANexplain the nature of the copy of this record ins been prnvidcd to'the wrll ou,wr.
repair under#21 remarks 4;nfivrt yr un the bark of this farm. t 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use-lie back of this page to provide additional well site details or well
construction,only]�rW-1 is needed" Indicate TOTAL NUMBER of wells construction details" You may also attach additional pages if necessary.
drilled: / ` ]'l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t l� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple ur/A list all drpdrs ifdifferent(l,rample-3@100'and 2C/001 constriction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
if water level is abom,ceLving,tie'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1!'8 (in,) 24b.For infection Wells: In addition to sending the fort 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: constnic6on to the followin-
(i.e.auger,rotary.cable.direct push.etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Dian Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test- Air Flow 24c.For Water Supply&Injection 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: 1 112 Lbs completion of well construction the county health department of the county
where constructed.
Form Gw•-i North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016
I