GW1-2022-09741_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD (GW-1) rFornternal Use Only:
1.Well Contractor Information:
Robert Teague
FROM TO DE.SCRn'TCON
NVell Contractor Name 0 ft. ft.
B &K Well Drilling Inc ft. ft.
NC Well Contractor Certification Number 2C:OF3[EI2 GiL571vG: iuiutti�ased'`tiY'AS'-DR
2857-A FROM To DIAMETER TMCIs-NESS MATERIAL
U ft. ft. 6118 SDR-21 PVC
Company Name 7S:li�1YERGl GUR kI&fP1G ebi8ermal.clusedloe
2.We1L 3
Construction Permit �� 1 L2 S FEN.I TO DIAMETER THICKNESS MATERIAL
T.isl all irpplieablc well cortsp:uction permits(i.e.L71C.County.Stare.Variance,etc.)
rt fit. In
3.Well Use check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaVPublic ft ft. in.
Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) rt ft. in.
u 1 (sh
ared)
d
' Water S )ual'den -
est Sup
ply
lndustriallCortlmeroial zFR3: Rt7
FROM TO hLATERLAI, E6IPLACEMENT DIETHOD 8 AMOCfiT
rAquifer
ft fc
pply Well:
nRecovery fit• fir•
l: rt. ft.
Croundwater Remediation , . ,:_ _.. :::.::::::::::::.: ::::::.::::.:::.:. ::•:.
harge >19AIYfXGR4YFt L'4CKtif iieeblefi:;>:>.:::;;»>;::;s
rdge and Recovery E]Saliniry Barrier FROM TO MATE RL41 EMPLACEMENT METHOD
Aquifer Test oStormwatcr Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) E3Tracer Z�.:DRT1EIhTGflt :adacf'sHdrtitiiiaksheetaimcess
FROhI TO DESCRIPTION color,hardn S.sol0rock n tutu size,Mc)
Geothermal(Heating/Cooling Return) Other(explain under 021 Remarks)
Well ID# ft.
4.Date Well(s)Completed: —•C ;`*��
V
5a.Well Location: rt � �• �Y L.
. ds rt. S n.
acI16 Abw c\/ 1Syyle S ft. ft.
ility/Owner Name Facility 1D9(if applicable)
rt. rc.
[') i 7 •P n � r�,
PhYs ical Address,City,and Zip
:.
2I:12E1►1ARKS'<'' ': ..,..:,..:.....r..:: ._....,._.....
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lnl cf,mtv�w Una
(if well field,one[atilong is sufficient) 22.C atrons��
N W ()
signature of Certified ell Cun ter Datu
6.Is(are)the well(s)OPer•manent or Temporary
By signing this(onn,1 herelry certify thar the xrll(.c)wac(were)corcuntcred in accordance
7.Is this a repair to an existing well: 13Yes or No nilh 1.5A NCAC 02C.0100 or 13A NCAC 02C.0200 tve11 L-onsrrucNon Standards trod that a
this(s a repair,.lill out known well construction information and mplain the nature of the copy o(this record ha been provided to fire wrll owner.
if
repair under m21 rennarks section or on the back ojrhis form' 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
constmetio4sonly I GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages ifnecessary.
drilled: Gf SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple,wi/.a liar all depths i(dii ferent(exanple-3,_,"Oa and 2 rr,10O) construction to the following:
40 ft- Division of Water Resources,information Processing Unit,
10.Static water level below top of casing: ( ) 1617 Mail Service Center,Raleigh,NC 27699-1617
ljwater level Ls above c2cimg,use"+"
11.Borehole diameter: 6 1/8 (in.) 24b.For injection Wells: Tn 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 constntction to the following:
(i.e.auger,rotary.cable,direct push.etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY
�WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
`y Method of test Air Flow 24c.For Water Suably&Injection Wells: In addition to sending the form to
13a.Yield(gpm) the addresses) above, also submit one copy of this form within 30 days of
Chlor Tabs Amount 1 112 Lbs completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
I
i
Form GV.'-1 Norh Carolina Department of Environmental Quality-Division ofWater Resources
Revised''_'_-3016