GW1-2022-07359_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
• I
Robert Teague
. .. ..... :. .
FROM TO DESCRIPTION..
Well Contractor Name . C b ft' ;'6 T fL
B&K Well Drilling Inc 7a rr. 75 rt. G
NC WeIi Contractor Cettific ation Number
s15 0UTER:CA.5lNG fgr'alatttctssed:::ivelk;Elg'1,If11 R'i[:`' "" ...........
2857-A FRONT To DLIMETER TfiICKNE.SS NLATERIAL
o ft. ft. 6 tra in SOR-21 PVC
Company Namc
I6.0T!I>rKG;f;SIFEG9It'E11HililG atelased-Eov ::
�( (7 THICKNESS
MATER14L
2.Well Construction Permit it: FROM TO DIAMETER
� !�
List all applicable urll cotsrntction permits/i.e.UIC.CAIafN.State.Variance,'lc.) fc. l N/�V IL
L- J!
fL in.
3.Well Use(check well use): fL
Water Supply Well: FROM I TO DIAMETER NWT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public
Geothermal(Hcating/Cooling Supply) MRcsidcncial Water Supply(single) fL in.
eel __...._ :::::::::.::
:]Industrial/Commercial OResidenual WaterSuppl,v(spat )
irri ation FRUNE TO NL� ENiPLACENrENT NWMOD&AMOUNT
Non-Water Supply Well: tc. ft-Monitoring [3Rccovcry ft. ft.
injection Well: ft. ft.
Aquifer Recharge [3(aoundwarer Rernedi4ion - ^
19ii5AiV#)!G'RAtiEf iIS4CK'Gf...,::.,.::„ :>;:;;i i>>.;;'<'>i:::>:>zz:a>s:... . : ::.::......;:::s........
Aquifer Stor9ge and Recovery [3Saliniry Barrier FROM I TO 9L4TERLIL EMPLACEMENT METHOD
AquifcrTcst [3Stormw3tcrDrainagc ft. fi.
Experimental Technology [)Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 28:BRiLfIt7G10:.:atiach.addrt►oiiitk3beetssf
FROM TO DESCRIPTION ce r.hard twilroek main sac-etG)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
4.Date Well(s)Completed4o-L Ll--aa-Well ID#
" Sa.Well Location:
ft ft.
Facility/Owner Name Facility ID9(ifapplicable) ft. ft.
CiL-I t l �/t�?'l �!Y• Sheri-�1S �a✓j
ft. ft.
Physical Address.City.and Zip
yl:trFiu'ealcfi 3:;
C��c�cr.r�c�•
County Parcel identifia+tion No.tPiN) ve v.woA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I DW
(if well field one far/long is sufficient) 22.Certificatio
W � 1/�/l•�z
6.Is(are)the well(s)IgPermanent or Temporary
Signaturcuf Certified We ontractnr Datu
B-signing I&T form,I hereln certify rear the xrll(s)was tx•cre)eonsrrtretad in accordance
7.Is this a repair to an existing well; E)Yes or EkNo frith 15A NC.4C 02C.0100 ur ISR NC AC 02C.0200 well Cunstruariun Standards and that a
!f this is a repair,•fill ota knoxn well ennstmetion iq nnnation and explain the nature of fhe copy of this record ilas beer,provider/to the well olde,.
relruir under 9l1 remarks section ur on thr buck of this furs. , 23.Site diagram or additional'well details:
8.For Geo robe/D)'T or Closed-too Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction
construction,only I GW-1 is needed. Indicate TOTAL NU.NIBEconstructiondetails. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 243. For All Weils• Submit;this form within 30 days of completion of well
For multiple tre//s list all depdts ifdillerent(:trample-3�-200'and 2@100� construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
lfwvrer level m al ove caring,are-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter; 6 /8 (in.) 24b.For infection 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: construcuon to the following:
I.i.e.auger.rotary,cable.direct ptulL etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) 3 C) Method of test: Air Flow 24c.For Water SuPRIV&I iiection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection tY3te: Amount:
Chlor Tabs t 1/2 Lbs completion of well construcrion'to the county health department of the county wherr
e consu'uctctl.
Form GW-1 North Carolina Department of Environmental Quality-Division of Rarer Resources Revised 2-21-2016