GW1-2022-09775_Well Construction - GW1_20221027

WELL CONSTRUCTIO 1`7 RECOP.I)(GW-1) Forinternal Use only:
1.Well Contractor Information:
Robert Teague _..::.::.................................
Well Contractor Name FROM TO DESCRIPTTON
B&K Well Drilling Inc G.5-ft• 1a fL
ft.
NC Well Contractor Certification Number u
2857-A FROM To DUMTER THICKNEss MATERIAL
Company Namc 0 fL ft. 6118 lo• SDR-21 PVC
Z.Well Construction Permit tl`: FROM TO DIAMETER THICKNESS 1 MATERIAL
List all applicable well comiruction permus li a UIC.C ouury.Slate.Variance,ate.) ft. fL in.
3.Well Use(check well use): ft.We'
is WaterSapplyWell: 7...._. ,.,::,:.::::..«, .::>;;:;•;:,.; ;::.::,.::..;:.«:;;:;:.:•<;.;:><,;;.::;:;.,:<:;>::.:;>z:><::<::»zz::z:;;
FROM TU DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural oMunicipal/Public ft. ft. in.
Geothermal(Rcating/Cooling Supply) RResidendal Water Supply(single)
ft_ fL in.
Industrial/Commercial esiden[ial Water Supply(shared)
], Irrigation
FROM ..:TO s:.ipL1TERLAL E!KPLACEI1gNT METHOD&�•1M0[J!VT`:;
Nun-Water Supply Well: ft. It•
Monitorin. ORecovery tt. ft.
Injection Well:
ft. tt.
Aquifer Recharge Groundwater Remediation
A uifer Stord a and Recovery l �Salinity Baer :<FROM RT4o �:4hC�fSU TE RLAL :..:....:.:.
EMPLACEMENT aIETHOD. •
DAquifer Tcst oStormwarcr Drainage ft. ft.
Experimental Technology Subsidence Control fr. ft.
QGeothermal(Closed Loop) Tracer ?Z 'FiY 1 Oiw'atiacl'adcGigef efskceira£ ` ` >?<>::::::»<<::zz<i?;:•3`. >;; ;<;:`:r
FROM TO Geothermal(Hearin Coolin Return) Other(explain under T21 Remarks) fL Tt. DESCRIPTION color,hardn¢ss solurock tr oryin Sue.Mc
\`( 4.Date Well(s)Completed: D '�I Z�Well ID# s ft.
Tc-
a.Well Sabo Sit. d it.
, R ft.
-0' Faith /OwnerNatne ft.1Y Facility iDf1(ifapplicable)
Physical Address,City,and Zip
. i
Ys
N
X. ..ltF3s3e)IiK>5..
County Parcel identification No.(PiN) OCT 2 7•.2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,onelatllongissufficientj ,}liui''rl?o►.�t+� t `-'`%^'''r"^"- .
22.Cer do r.4Atr'� a
N W J <1-;)C,
6.Ware)the well(s) x Permanent or OTemporary Sipwturu of Certified Well Conydetor Datc
$v signing thLc Yarn,I hereby certify that the well(s)war twere)eomrntered in accordance
7.Is this a repair to an existing well: DYes or No vith 194 NCAC 02C.0100 or MA NCAC 02C.0200 well Construction Siandarth and that o
lfthit is a repair,,ftll out btoxrt well cnastntction infannazion and iklain the nature ofthe copy ofthis record has been provided to the xell ow7cer.
repair under'Ql raouv-k�section or on the bat*ofthis fonn.
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
con=iction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary,
drilled: SUBIMiTTAL INSTRUCTIONS
9.Total well de below land surface: (ft-) 24a. For All Wells: Submir this form within 30 days of comple6otl of well .
Far nialdple welts list all depths ifdifferent(ctrmnple-3@260'and i tt 1001 construction to the following:
10.Static hater level below to of casing:40
p g: (ft) Division of Water Resources,Information Processing Unit,
if water•level is above cacine use-+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (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: construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lhs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type. Amount: completion of well construction to the county health department of the county
where consnucted.
I
Form GW-1 North Carolina Department of Environmental ep Quality-Division of Water Resources Revised 2-221-?016