GW1-2022-09781_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD(GW-1) IrI11Fortrt
For internal Use Only:
1.Well Contractor Information:
Robert Teague
WeIl Contractor Name FROM TO DESCRIPTION
B&K Well Drilling Inc 6 S 6
ft.
NC Well Contractor ft.Certification Number
OFI'EEiliGAi5711IG� ::;ai�fi='rssi�iisre)fc':E3Ri3 '�'::.::. :"i?:?':' :<i;r:>;:;�;:•!;:<i
• 2857-A FRODI TO DIAMETER IffiCKNESS MATERIAL
Company Name 0 fL I` ft 61/8 �• SDR-21 PVC
::1GiNiV1 H.FkI}�E�Jplt>.USl�lri"eet6eituahzlosedo8'" i i<:'; Ei< E?•s;'3:::::Ei` ':a
2.WQII Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well co»srruciion permits(i.e.UIC(:omav,State,Variance,ctc.) fL fL in.
3.Well Use(check well use): ft. tt. in.
V
Sn I W PP Y ell. l'ROAITO DIAMETER SWTSIZE THICKNESS MATERIAL
cultural ElMunicipal/Public n fL in
Gcothcnnal(Heating/Cooling Supply) Residential Water Supplv(Single)
1ndU
IL fL in.
rc,tal esidential Water Supply(shared) :
.. rogation FRUbi 70 .. 11L1TERSAL E.'t�I,ACEMENT11tETHUD&.AMOUNT
No -Water Supply Well: ft. fL
Monitoring, DRecovery tt. fL
Injection Well:
AquiferRecharee C)GroundwaterRemediation tt' tt-
tf19:SeYiY1)lGRAka'KCifif' eafiile?i::;<;:``.:%it:::;3: i?si <i:'• "::iE:iC !::;si•':::
Aquifer Storage and Recovery ............................:..:::.,:...
q $ ry' �Saluury Barrier FROM TO 11LATERLAL EMPLACEMENT METHOD
AquifcrTcst �StormwatcrDraina-c ft- ft.
(DExperimental Technology - E)Subsidence Control ft. fL
r-lGeothermal(Closed Loop) DTracer
lifif,}::ill"�:1:t3C`aitacTisdtGhe3na}� ::::,.:•.::::::::...::::.:•:....,,,, .
Geothermal(Heating/Cooling Return) Clther(explain' under#21 Remarks) FROM TO DECRIPTION rnior.naranecs solvroct n"m to srza crc)
rt. 106 ft.
II 4.Date Well(s)Completed: - 2), Well ID# ft. 06 ft.
Sa.Well Location: Oc!5 ft- n•O fL 'r. �.S
p rL ft.
Facility/OwneMamz r Facility ID#(ifaoplicable) ft. fr-
t 7 a. -A t- ter fL ft.
Physical Address,City,and Zip ft. ft. `
ra
23 IZE33AR1{53:::<s::
County Parcel ldentifieazion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 2022
(if well field,one lat/long is avfficient) 22.Certif n•
6.Ware)the well(s) x Permanent or OTemporary Sigiwtun:of Ccitificd Wcll Contr )r Date
Lit signing this form,I herehv eenrfy that the xxllfl)was(x•crc)comnucted in accordance
7.Is this a repair to an existing well: DYes or GNo ,'ith ISA NCAC 02C.0100 or ISANCAC 02C.020O Well Construcdon Standards and that a
(/'this is a repair,ill our lmoxa well construction ittfo nano»and lain the nature ofthc copy-ofthis record has been provided to the well owrdcr.
repair under#21 renua$u section or on the back of this furor.
' 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-I is needed. indicate TOTAL NUMBER of wells constriction details_ You may also attach additional pages if necessary,
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 70 O (ft) 24a. For All Wells: Submit this form within 30 days of completiou of well .
For multiple ivells liv all depths ifdifferent(arainple-3r,100'and 2@100� construction to the following:
10.Static water level below to of easing:40
p g: (ft) Division of Water Resources,Information Processing Unit,
If wafer level Ls above casing use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (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 etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 LY
13a.Yield(gpm) L/ Method of test:Air Flow 24c_For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chloe Tabs Amount: 1 U2 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 Resources Revised 2-22-2016