GW1-2022-09743_Well Construction - GW1_20221027

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague
.. ..... ............ .....
FROM TO DESCRTP77ON
Well Contractor Name
B &K Well Drilling Inc
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NC'Well Contractor Certification Number """'
?C�i:OEfTERiGASII`1G:fotz`tnniti=cased'Nelle':©17i 3N1f iE•'' limble'::>:r.:<i':z<'::>>ia:
• 2857-A FRO51 TO DIAMETER THICKNESS MATERIAL
p ft. ft. 61/8 �' SDR-21 PVC
Company Namc
16':1N1VER' ::TiU$fAIG eetkexma€"closed l06 ::.
r-V,,l FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ^ ft h in.
List fill applicable well consrntction permits(i.e.L/C.COWlty.Siuie,Variance,etc)
(t. ft. in.
3.Well Use(check well use):
V
Supply Well: FRohl TU DIAM1I ETER SWTSIZE THICKNESS M17.4TERIAL
cultural rIMtmicipal/Public ft ft. in.
r'lGeothernrial(Acating!COOling Supply) Residential Watcr Supply(Single) ft ft. in.
e
industIndustrial/Commercial 'Residential Water Supply(shared)
IrrioB[iUn FROM TU DIATERLAL EIfPLACEMSNT METHOD B NMOCINT
ft. ft.
Non-Water Supply Well:
(Monitoring DRecovery h. ft.
Injection Well: ft. ft.
ClAquifer Recharge E)Groundwater Remediation
5ANi)/GR4YEL 1''AGI+[lta 'liciible)
Aquifer Stor9ge and Recovery DSaliniry Barrier FRODL TO DLATERLAL EMPLACEMENT METHOD
r3AquifcrTpst �Stotmwatcr ft. ft.
Drainagc
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) [)Tracer I"66:atts&'-'ii 6o3ia3sheetsrfnecess a.............::.. :::...
FROM ft.
DESCRIPTION rnlor.h n¢.as.sotVrocA ri amain size,era)
Geothermal(Heatin Coolin Return) Other(explain under A21 Remarks) ft tt
B ()l -
4.Date Well(s)Complete
pLL____1)_aVel11D# G
ft• R. v
ft. ft.
5a.Well Location:
rt. rt.
Fa tlity/Ow�ame Facility 09(ifapplicable) ft. ft.
ft. ft.
tt. ft.
Physical Address,City,and Zip -
M �., ;r c OS'5—3r�o� -if G v
County
Parcel Identification No.(PIN(
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,e
(if well field,one latllong is sufficient) 22.Certif 'On:-----�
Emat n:of Certified Well Crn aeUu Dale
6.ls(are)the,vell(s)OPermanent or [3Temparary
�q By.signing this form.I hereby certify rhat the well(5)wets 1x-cre)consrnrcted in accordance
7.Is this a repair to an existing well: 12Yes or MNo ,irh 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standonh and that a
cope ofthis record has keen provided to the well ouRer.
U'tht's is a repair,Tll out knoxa well Canstntction information and explain the nature ofthe
repair under R21 rentarl s section or on the back of this fonn. 23.Site diagram or additional well details'
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages ifnecessary.
drilled: �] r\ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: rT l 1 (fir) 242. For All Wells: Submit this form within 30 days of completion of well .
Far multiple url/s llst all depths ifdijferent(:rarnple-_!a^00'and 2 a 100� construction t0 the YollUwirh:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifsvter level k above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 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.Wen construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3\) Air Flow 24c.For Water Supply&Injection Wells: hi addition to sending the form to
Method of rest
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type:
Chlor Tabs Amount: 1 112 Lbs completion of well construction' to the county health department of the county
where wnsuvctul.
Form GV'-1 North Carolina Department of Environmental Quality-Division of Water Resources
Rev sed 2-22-2016