GW1-2022-09822_Well Construction - GW1_20221028

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WELL CONSTRUCTION RECORD (GA-11 For internal Use Only:
1.Well Contractor Information:
Robert Teague `>::;:.;:::::;:::;:F::::;;>::;;.
FROM TO DESCRIPTION
Well Contractor Name rt. ft.
B&K Well Drilling Inc rt. ft.
NC Well Contractor Certification Number " "' .......
':>15i 011 FER'GiLS7t G orate. Ptls
2857-A FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ft, 61/6 in. SDR-21 PVC
Company Name `� %� 1611!liiTEAfAS1l9. {3RF111IiI!1C: tbesma}tlusrd=loo
1 t 1
2.Well Construction Permit#: l FROM To DIAMETER in. THICKNESS MATERIAL
List all applicable well contruction permit ii.e.U1C County.State.Variance,etc.)
ft. ft
f[. ft. in.
3.Well Use(check well use):
sX
x :.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipa/Public ft ft. in.
Goothcrnal(Hcating/Cooling Supply) Rcsidcn[ial Water Supply(single) ft. fL in.
lndustriaUCommerLra 1
esida s'al Water Su
pply
P1Y(shared)ared
)
FROM51
TO M&TERLAI. EhIPLACEMENT METHOD aAMOItNT
-. lrri anon
ft.Non-Water Supply Well: ft.
Monitoring [3Recovery ft. ft.
injection Well: ft. ft.
Agmfer Recharge
Groundwater Remediation
19c:. A9 VSNGR9yF :#'AGKGf
Aquifer Stor2ge and Recovery Salinity Barrier FROM TO ➢LATERLAI EMPLACEMENT METHOD
Aquifer Test C)Stormwarcr Drainage ft. ft.
Experimental Technology [)Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer <:Sd::DRIIf3`IG:IAC:itttaclraddiht)nAliheets:Sfriece3 <::??>::>:«% ;g >:::> F:F':5:<:>:>:
FROM TO DESCRIPTION rnlor.ha ! solVrockt%..4 Rrsinstzc,cte.)
Geothermal(Heating/Cooling Return) nOther(explain under 921 Remarks) ft. -:> ft.
4,Date Well(s)Completed: T yZ Well ID#
ft. ft.
5a.Well Location: �9 lit )C'X Y
�^���-5 `� ft. ft.
Facility/Owner Naate Facility iDk(if applicable)
ft. ft. � .r'j i
fr. t t V
Physical Address,015.aad Zip
4
rfJ.S�h\�
Q LULL
County iREdiD3RK5 ''Parcel identification No.(PiN) r^� i,
Inforn�.i i Prl�,'.�f,3iuri. i�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif 'on:
N W 2 o o Z1LL-Z--
Sitmatum of Ccrificd Wdl C nacu>r Datc
6.Is(are)the well(s)OPermanent or [3Temparary
By signing this(orni.1 hereby certify that the xrllit)was/were)constructed in accordance
7.Is this a repair to an existing well: Oyes nr No ,-ith 1 SA NCAC 02C.0100 or 19A NCAC 02C.0200 Well Construction Standards and that a
f[hi5 isa I'Cl7Qi1',fll our�a77abn well constructionInfaRnalia and .plain the nature oftive copy o(this record has been provided to the will owner.
repair under 921 renttais section or on the hack 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: C SUBMITTAL INSTRUCTIONS
9.Total well depth elow land surface: A) 242. For All Wells: Submit this form within 30 days of completion of well
Fob•multiple ivellr lire all depths ifdii ferent(example-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'ivater level is above caring,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,rouiry.cable,d'ucct push,etc.)
Division Of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
73a.Yield(gpm)
Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county'health department of the county
13b.Disinfection type: where constructed.
Form GV.'-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-"-2016