GW1-2022-07363_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague
t4.WAil ER�ONB'
FROM TO DESCRIPTION
Well Contractor Name Sul ft. As,
B&K Well Drilling Inc ft. rc,
NC Well Contractor Certification Number
1S:OI)'FE12:G:1S7t�iG fots:otattr d;4vel �lt` ll�lit it
2857-A FROM TO DIAMETER THICKNESS I MATERIAL
0 ft- ft- 61/8 in. SDR-21 PVC
Company Name �.(�] � 16;>1ivNERf 51NG OR Ft38tl!IG 'eetTierrn cla.....
2.Well Construction Permit##• � I FRO DIAMETER THICKNESS MATERIAL
list all applicable well construction permits 0-a UIC.C:omury, ate.Variance,etc.) ft. ft• m.
fL f[, in.
3.Well Use(check well use):
Water Supply Well: FROM I To DIAMETER SWT GAZE THICKNESS MATERIAL
Agricultural ®MunicipaUPublic ft tt. in•
Geothermal Mcatin g/Coo ling Supply) RfResidendal Water Supply(Single) ft ft. in•
Industrial/Commercial
erctal
esidenual Water Supply(shared)
R ::;<»:::;:::>;
t1i� D
'.irrigation FROM I TO NIA TERIAr. rNfPI.ACEMSNTDtETHOD&.AMOttNr
Nun-Water Supply Well:
Monitoring [3Recoery
injection Well: tt. ft.
Aquifer Recharge E]Groundwater Remedi4ion
19.SAiVtNGYttY.V1 1 f!4CiC Gf. livable .:
Aquifer Storfige and Recovery [3Sa1iniry Barrier FROM TO 11LATERL4L EMPLACEME`tT METHOD
Aquifer Test [)StorTnwarcr Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 28'BRTj.EIA1CtiGQ. attaeh.adtrtiia#'s7teefsaf
FROM TO DESCRIPTION color. '"fumek insire,etc.)
Geothermal(HeatinglCooling Return) nOther(explain under 421 Remarks) ft. tt.
i
4.Date Well(s)Completed: Well ID# a R- fL Y' C—
ft. fu
5a.Well Location:
! ACI I QH IL
ft. ft.ft.
Facility/Owner Nance Facility lD if applicable) .-..
S ft.
Physical Address,City,and Zip
Ufa.;:
County Parcel identification No.(PTN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
01'well field,one ladlone is sufficient) 22.C rtification•
N W d
r_tatatuto. Ccrificd Wcll Contractor Dal.
6.is(are)the well(s)�x Permanent or Temporary
�.�t By signing this/brit,1 hereby certify that the xrlks)wets(xerc)constructed in accordance
7.is this a repair to an existing well: DYes or �(f No with 1 SA NCAC 02C.0100 or 15A NC.4C 02C.0100 Well Construction Standards and that a
//'this is a repair,ell bat known well construction information an xplain the nartire ofthe copy ofthis•record has been provided to the well owner.
repair under 921 remarks s;m-tiorr or on the hack of this;fonm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
b.For Geoprobe/DPI or Closed-Loop Geothermal Wells having the same
constniction details. You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: A SUBMITTAL INSTRUCTIONS'
9.Total well dep r below land surface: �C� (ft-) 24s. For All Weds: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifdii ferent(trample-3@200'and 2©1001 COIISl7t1C[i0II to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
if"r'arer level is al love casing,ate••+" 1617 Mail Service i enter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 �8 (in.) 24b.For iniection 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: construction to the following:
(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) Method of test: Air Flow 24c-For Water Supply&Iniechon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs 1 V2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type: Amount: p
where constructed.
Form GV.'-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised'_'-22?016