GW1-2022-09866_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW 1) For Internase Only: J.
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1.Well Contractor Information:
Robert Teague y1CNATE16Zt3NES
n.PT,,
FROM TO
Well Contractor Name DESCRIPTION
2857-A ft• ft.
ft. fr.
NC Well Contractor Certification Number
SS:AIITER CASING,far:muCh caseiT A db OR R: 1iraUle: r?s B &K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company N C ft. 7`Z) ft- 6118 in.
P Yame SDR-21 PVC
^ s:16:'I19NERGA�INCOR;'f7BINS`"eutberxnal:c[osedia»"�r �<.. k
2.Well Construction Permit#C-`^\W �6Z ^ IJ S�qr� FROM TO DIAMETER THICKNESS a MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. rn.
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17:?�G1tEEN,
a ..._..,. _,a.
:]Agricultural MllnlCl aUPubliC FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
p ft. ft. in.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single)
ft ft to
Industrial/Cornmercial [3Residential Water Supply(shared)
A.: a aty_-Iii'i at1On FROM TO MATE L E LACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft.
Monitoring ��
ft. ft.
Injection Well: DRecovery
a
:]Aquifer Recharge ft. ft.
q gGroundwater Rcmcdiation
19'SA1D/,t;12Ai?ELPACIC da Scatile :-
Aquifer Storage and Recovery Salmi Barrier • -
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.aDRYT T f11TG'T QG attachadthttotissheetsae =
Geothermal(Heating/Cooling Return) 10ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solyrock type,grain size,etc.)
ft.
?g v 1
4.Date Well(s)Completedq Z?Z Well ID# ft. ft.
5a.Well Location: ft' 40 ft'
ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft.
Li c 'Iv� 41
County Parcel Identification No.(PIN) r ..,,a; r'Z4gq Urih
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Dk%fQ/
(if well field,one hat/long is sufficient) 22.Certifications
N W
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6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Cont [or Date
�d By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or @/QNO with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
/fthis is a repair,fill out known well construction information and eNlain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:_ 3 L� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 11 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 �8� (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L y Method of test: Air Flow 24c.For Water Supply&Iniection'Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to th`e county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016