GW1-2022-09782_Well Construction - GW1_20221027

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague tTlcarR:zolvl;s:::;<:;::>•>:»>;:.;>;:< ::::;<.:::>r>::::.:s;:a::»»:>::>:<:>:>:<:;;:;:.<::>:>:>:><:;::>::>:>;:.><:::;><::<:;:;:>
FROM TO DESCRTPTrON
Well Contractor Name
o
B &K Well Drilling Inc p`
�5 it-
S o n- J! It- A-
NC'Well Contractor Certification Number o: - """"' '"^`......
<OE#'GE}Z>GASING_,atlililr' •tiElls'E3&i3�1�• ..
2857-A FROM TO DIAMETER THICKNESS MATERIAL
0 IL t. 61/8 in. SDR-21 PVC
Company Name
2.Well COnStiDCilOn Permit(�' FROM TO DIAMETER THICKNESS MATERIAL
rise all applicable well construction permits 0.a.U1C•Couty,State.Variance,etc.) fL fL in.
3.Well Use(check well use): fL ft. in.
3#i'i'• f::.::::ii`i .2 ::i'i.......
Water Supply Well: FROM TO.... __.DIAMETER....SWTCIZE THIC. .. .._. .. ... .. .. ._
KNESS MATERIAL
Agricultural E]Municipal/Public ft. R. in.
Geothermal(Acating/Cooling Supply) Residential Water Supply(Single) ft- fL in.
x .vIndu trial/Commer cial CSIdential Water SuPP1v.
(shared)
%<?': 5i%'_:i:% > > '�:
. Irrigation FROM TO AL•1TERLgL EMPLACEMENTAIETHOD&—AMOIt1,T
Nun-Water Supply Well: ft. iL
Monitoring ®Recovery ft. fr.
Injection Well:
ft. ft.
Aquifer Recharge [3Ctroundwacer Remediation
iil'9::Si4iYtNCIZhV:EI;i',!TC�Ift`a beablc ;:.;'.;:;<:;::::;::•.
Aquifer Stordge and Recovery OSaliniEy Barrier FROM TO NLITERIAL I EMPLACEME-NrTIETHOD
nAquifcr Test [3Stormwa[cr Drainage fc. ft-
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) nTracer 2>#'BItILEhYG#a1C attac(iadsGaefie3`sa€`` <. . >:
FROM TO DESCRIPTION color, rdncss. otl/rockn main size,etc)
Geothermal(Hearin Conlin Return) Other(explain under T21 Remarks) I 1 ,i..�
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4.Date Well(s)Completedq-- — Z 7;Well ID# ft* L
5a.Well Location:
�.c,y s e.►� a- .0 \�(�✓ ft. Qit'
Facilli /owner Name'i 1 Facility IDr(if applicable) ft. ft-
�S tl 1 (e ��✓ ft. ft. 77 n w—9 1-, ,-
Physical Address,City,and Zip
>'2
County Parcel identification No.(PIN)
5b.Latitude and longitude in de reel/minuteslseconds or decimal degrees:
Ifiii,ti74rZ3 i1 P!,�s �`
s s
- (if well field,one Iatllong is sufficitn[) 22.Certif -
N W
6.Ware)the well(s)arermanent or Temporary Signatutc of Certified Well Con ctor Date
15v signing t&c form•1 hereby certify that the xrllts)was(were)constructed in accordance
7.Is this a repair to an existing well: �l es or o with I JA NCAC 02C.0100 or I19 NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,ill our bioMvt well canstruczh tafannat)ntt d rplain the nature of the cofiy of this reenrd has been provided to the well owner.
repair und(T 921 rentar*s section or on the bark of this farm.
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
constntc[ion details- You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O (ft) 24a. For All Wells: Submit this form within 30 days of comple6ouu of well .
For multiple me//s list all depths ifdi fferent(i ratnple-3v 200•and 2@1001 construction to the 40 following:
10.Static water level below tap of rasing: (ft) Division of Water Resources,Information Processing Unit,
!j'uater level is above casing;use•+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Tniection 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 posh,etc-)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Dian Service Center,Raleigh,NC 27699-1636
132-Yield(gpm) L Method of rest:Air Flow 24c-For Water Supply&Injection 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: Chlor Tabs Amount- 1 1/2 Lbs completion of well construction to the county health department of the county
where consmuctcd.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Rev,sed 2-22-2016
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