GW1-2022-09819_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD (GW-1) I For internal Use Only:
1.Well Contractor Information:
Robert Teague E:E:i<f i. i;':':i: :G: ::»:i:::::' `:.`'•:E::?•;:: ;<i:i:i >
FROM TO DESCRIPTION
Well Contractor Name is ft. ]Lr` ft. ( /: I J
B &K Well Drilling Inc ao «- 1S
NC Well Contractor Certification Number <:1:Si0if I ER C3 7YG ttrceEdrelk':ElH'i#�A'2857-A FROM TO DLIMETER THICKNESS AUTERIAL
0 ft. V fL 51/8 In. SOR-21 PVC
Company Name V
.IG`1ivNERG�i.SFlslG:fi)R'Elt$iNC+:,. t�el�'S2'closed-toe•'. ::,;:'>:;`<:•>:: •:
2.Well Construction Permit#/• IS 7�� FROM TO DIAMFiTER THICKNESS MATERIAL
List all applicable well construction permits fi.e riC.Cowgv.State.Variance,etc.) ft. ft. m.
3.Well Use(check well use): IF
Water Supply Well: FROM TO DIAIIETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipai/Public ft. ft. in.
Geothermal(Hcating/Cooling Supply) VIResidcruial Water Supply(single) IL ft. in.
.,,,...:......_...,::< r::;:•;;>;:;:;•:: o:o-:i5•Y:;:>+:;;;$;5:;:>;:;;:;<;:;;:«:GS:;;'::::: ::;i::£fi::c::8>:::;x8;q?:«:
Industrial/Commercial Restdenual Water SuPP1Y(shared) .>:tff:GftDb3:;:;;:.:::.;:;:;:,:.>:>::;».;;:;<.;::.::.,:::::::.::::::::.;.:::::;:.::::.:::::::;::,•::.:::::.:::.::,:::::-::::::•.
irrigation FROM TO nL•1TE'RIAL EhfPr.ACSMSNT DIETHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery - FIE .,ft. ft.
injection Well:
Aquifer Recharge []Groundwater Re Ton 6 .2
Aquifer Stor-2ge and Recovery [3Salinity Barrier MINI TO .7%UTERLa1 EMPLACEME`rTAIETHOD
r Aquifer Test OStormwa;:40-31100'0n pr:`CS3 F+j urv'ft. ft.
C.. Cd3t
Experimental Technology [3Subsidence Control ft. fr.
Geothermal(Closed Loop) Tracer :7tf;61tTIsITNLf]".atlsichsddrtionatsheetslfnetx5s
FROM TO DESCRIPTION rnlor- rdnas mw
Oft r— rockock e. in sac,etc) .
Geothermal(Heatin Cooling Return) Other(explain under#21 Remarks) rL r
► r, 0 GL.
4.Date Well(s)Completed: -7v �`� Well ID# - p S iL —
W rc. «.• ✓
" S\a.Well Location:
ft 1
Cr1 r1QN. ft. ft.
Facility/Owner Name )) Facility 1D#(ifapplicable)
L i h���>^Ar�' ft. ft.
Physical Address,City.and Zip
County Parcel identification No.(PTN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latdlone is sufficient) 22.Certification:
N W 4a2.�_
6.1s(ore)the weil(s)oPermanent or OTemporary ipature of Certified Welln a 1 Cctor' Date
h;-signing this form,1 hereby certify'that the xr/1fs)was lxrre)c0nsmtcted in accordance
7.Is this a repair to an existing well: nYes or JRNo with 15A NC•fe 02C.01110 ur 15A N(:AC 02C.0200 Well Cunsiructiun Stondanh and that a
I#'this is a repair,ill our known well canstniction informadoll and lain the nawc ofthe copy-ofthis record has been prn.vided to the wrU omwr.
repair undr r 021 remar6w sectiva or urr the bark of this.furm. r 23.Site diagram or additional well details;
You may o attach additional pages if necessary.
use the back of this page to provide additional well site details or well
6.For Geo robe/DPI or Closed-Lao Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may als
drilled: A SUBMMAL INSTRUCfION:3
9.Total well de t elow land surface: S Ll S (fr) 24a. For All Weds: Submit this form within 30 days of completion of well
For multiple wills lisr all depi s ifdfi ereni ti rainple-3rX200'and 2@1001 COIIStrtCtlOII to the.following:
10.Static water level below top of casing:40 (fL) Division of Water Resources,Information Processing Unit,
If tearer level is atom casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in-) 24b.For injection Wells: Tn 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
13a.Vied(gp
Method of test: Air Row 24c_For Water Supply.&Iniection Wells: In addition to sending the form to
1 m) e
the address(es) above, also submit one't copy of this form within 30 days of
p_
1 112 Lbs - cti ii to the county health department of the county
Chloe Tabs completion of well con,au o t} eP
13b.Disinfection type: Amount: P
where constructed.
i
Form GW-i North Carolina Department of Environmental Quality-Division of Rater Resources Revised 2-22-2016