GW1-2022-09779_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD(GW-1) For internal use Only: i1�F�lFrn
1.Well Contractor Information:
Robert Teague
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Well Contractor Name FRODt TO DE•SCRIPTTON
B&K Well Drilling Inc 1-soft. fL
NC:Well Contractor Certification Number .
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•2857-A , FROM TO nTAMET'ER I THICKNESS I MATERIAL
Company Name 0 fL �ft. 1118 �• SDR-21 PVC
>16 1lVt�lirKE $1bEG E)tt {lJBI1�FG: cl osed 3oti`
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction penults lia U1C.t:otarty,Stale.Variance,etc.) ft. fL in.
3.Well Use(check well use): fL ft. in.
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Water Supply Well: .. :..............
FROM TO DIAMETER SLOTSIZE I THICKNESS.`•I.MATERIAL
Agricultural E)MuuicipaYPublic ft. ft- in.
Gwthcmtal(Ticating/Cooling Supply) taidcmial Water Supply(single) tL ft in.
hldustrial/Commercial esideatial Water Supply(shared)
G€t
Irrigation. .. FROM 70 t•L4TERLALI EMPLACEMENT IUETHOD L.AMOITNT
Non-Water Supply Well: tc. fL
Monitoring InRecovery ft. fr.
Injection Well:
rt. n-
QAquifer Recharge Groundwater Remediation
Aquifer Stor2ge and Recovery Salini Barrier fi1G1L4k�tMPLAC•: NIE''.MO
ty FROM TO �L4iERL4L EMPLACEME.vrDIETHOD
nAquifer Test [)Stormwatcr Drainage ft• ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTtacer
>1�: ;>E;(iLCsittac$adtGBe>iiik' :3�::::.
Geothermal(Hearin Coolin Return) Other(ex lain under g21 Remarks) FROM To ESCRIPT10N eolor. ¢cs soiV+ock to _—in sae.etc)
ft. MOIL
4.Date Well(s)Completed: Well ID# ft. `Jv r-
5a.Well Location:
fn ft. Y V e
7S'hY\ 0 t_ -o 1 305 fL tt kc
-
Facility/Owner ante Facility LDr(ifaoplicable) ft. ft-
r
c.rc E e c,e, 17-r i v�. ft. ft. .,�.
Physical Address,City.and Zip ft. ft.
County Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Iri'cr� a r{
(ifwell field•one latllong is sufficient)
i
6.ls(are)the well(s)aPermaneut or E)Temporar-y Silawtutn of Certified Welt Co ecwr Date
,,//////••• Ey signing this fonu,I hereby certify that the xc111.q wac lxrrz)consmicted in ace rdance
7.Is this a repair to an existing well: DYes or o bb'ith ISA NCAC 02C.0100 ur ISA NCAC 02C.0200 Well Construction Standards and that a
lfthit is a repair,fill out knoaa well constntction infannation n rpfain the nature ofthc cop}•oflhis record has been provided to the well owner.
repair under 221 rentar$s section or un the hark of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: 4 SUBMITTAL INSTRUCTIONS
9.Total well depth Wow land surface: S�'—[ 5 (ft Z4a. For All Wells: Submit this form within 30 days of completion of well .
For multiple hells ILst all depths/fdifferent terample-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,-Information Processing Unit,
If water level is above casing,rise-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (in.) 24b.For Iniection 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 push.ete.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Air Flow
Method of test: 24c.For Water Supply&Infection R'ells: In addition to sending the tblm to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 112 Lbs completion of well con zuerion to the county health department of the county
where construetcd.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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