GW1-2022-07399_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) I For internal Use Only:
1.Well Contractor Information:
Robert Teague iQ:wArE1t;ZOIv
FROM TO DESCRIPTION
Well Contractor Name / ft S- fL
B&K Well Drilling Inc o rt• IS ft. G, `Yr�
/ O
NC well Contractor Certification Number
>'.1500UFERCASIt�rG:
2857-A FROM TO DLAMETER THtCIiNE6S MATERIAL
0 ft. ft, 61/8 m SDR-21 PVC
Company Name
IG:1AN$R'G�tS11SG.UR:F(1$1CtG eetLermat:closed-too ;:..
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable Nell construction permits fi.e.UIC.County.State.Variance•etc./ ft. ft. in.
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM I To or AM ETER SLOT SIZE I THICKNESS MATERIAL
Agricultural []Municipal/Public fL ft. in.
Geothermal(Hearing/Cooling Supply) t-idcntial Water Supply(single) ft ft in.
e
denual Water Supply s hard ;..,.;. ..
Rest )
Industrial/Commercial p - as.G71UI]'i' 7777
irrigation FROM TO MOENTNon-Water Supply Well: rc
Monitorin; C)Recoccry ft.injection Well: ft.Aquifer Recharge [3Groundwater Remedi�ion
G[C 7: '<C'«;:>>:;:Aquifer Stor2ge and Recovery [3Saliniry Barrier FROM TO a1 EMPLACEr4E`rT METHOD
�AquifcrTest [3StormwatcrDrainaac ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 28` RIIsEIY� 'Lfl titttch.add€tturiti�sbleis:i[:aetxss-
FROM TO DESCRIPTION color,ftardn aautoek in sa eta)
Geothermal(Heatin Cooling Retunr) Other(explain under.921 Remarks) at,
E4,Date Well(s)Complated--1 Well IIT# 1-3 00
5a.Well Location:
ft
Facility/Owner Name Facility 1D",(if a icable)
�Sti e I ft. ft.
P real Address.City,and Zip
z..;.,
,e AIJ a -
County Parcel identification No.IPiN)
Z� U K9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: It
(ifwcil field,one lat/lonc is sufficient) 22.C2tion:��� 'rn'p����
N lb' 1
Sqfmaturu of Ccnificd Wcl nntractor D•aw
6.1s(are)the well(s)13Permanent or Temporary
By signing this forrn,I herehv certify that the xrIN)ww/x•cre)constructed in accordance
7.is this a repair to an existing well: 0Yes or No with ISA^"CAC 02C.0100 ur I m NCAC 02C.0200 Well Construction Standurds and that a
Ifthis is a repair•,fill out knoxn well ennstrtction information and explain the nature ofthe copy ofthis rernrd has hecn provided to the xrll goner.
repair under 921 remarks section or un the back of this.farm. 23.Site diagram or additional well details:
S.For Geoprobe/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
construction details. You may also attach additional pages if necessary.
constnlction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: �j SUBMITTAL INSTRUCTIONS
9.Total well deptw low land surface: ✓ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells list all depths ifdi(ferent(trample-3(1 200'and 3C100� construction to the tollotvin^:
10.Static water level below top of casing:40 (fL) D Asion of Water Resources,Information Processing Unit,
y'swtrer level is ahave.casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
in•
11.Borehole diameter. 6 /$ (• ) 24b.For Injection 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.cable.direct puslL etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,INC 27699-1636
13a.Yield(gpm) 1p� Method of test: Air Flow 24c. For Water Supply&Injection Wells: In addition to sending the form to
the addresses) above, also submit one cops' of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resnlrcces Revised 3-22-2016