GW1-2022-09868_Well Construction - GW1_20221028

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague T4z11CA.I'EiBZONE "
FROM TO DESCRIPTION
Nell Contractor Name tt. V/� (11�_ r3_
B &K Well Drilling Inc l ft• ft.
NC Well Contractor Certification Number
:1tiiOF1EEiZGAS7fiTGeiticssestisxifs:FlRi�3tt
2857-A FROM To DIAMETER THICKNESS NUTERIA
p ft. ". 61/8 1 in. SOR-21 PVC
Company Name
((,\`
2.Well Construction Permit#:I' F1 W1 - L J''1NDL FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable uvll construction permits(i.e.UIC,Cownv.Slate,Variance,etc.) ft. ft. in
3.Well Use(check well use): f[. f[. in.
ELM
_:7 SCR. _ ..........
Water Supply Well: FROM I TO DIAMETER SWTSIZE THICKNESS MATERIAL
Agricultural r3Municipal/Public ft. ft in.
Geothermal(Heating(Cooling Supply) WeSidencial Water Supply(single) ft g• in.
' Water Sup
ply(share
d)
ual v es iden )
•�a PP•aUCom merc,r 1 Industn
Irrigation FROM TO eMATERLAL : EMPLACEMENTNIETHOD&.AMOUNT"
Non-Water Supply Well:
Monitoring rlRecovery
Injection Well: tt.a Aquifer g uifer Recharge 0Groundwa[er Remediation
as:SetivnTG .� t.l'ACflfit Ircalile
Aquifer Stor2ge and Recovery DSaliniry Barrier FROM TO I%UTERUL I EMPLACEME`7T METHOD
r-lAqui ter Test C)Stormwatcr Drainage
Experimental Technology Subsidence Control fr. ft.
BGeothermal(Closed Loop) Tracer Z@ 1)RIUBING:1 IICi attach'sitBHtorial�heets; s:«>::<. ?<:o>;:•;_>s::::<:;>:
FROM TO DESCRIPTION color. ness,soiVmcti type.giVin size,etc]
Geothermal(Heating/Cooling Return) rJOther(explain under m21 Remarks) g, ft.
4.Date Well(s)Completed: ft- ft.
ft. D rt.
5a.Well Location:
` f i ft. ft.
R
1�� 1 Y'Ity �►�5 ft. tt.
Facility/Owner Name
' n` Facility 1D4(if applicable)
ft.Ir -� ft. ft.
Physical dress,City•and Zip -
County Parcel ldentifieation No.(PIN) ntiiiill?<�ft^1 i-`MO 5✓ 0(JRe
a
5b.Latitude and longitude in degrees/minutes/secondsr.n or decimal degrees: be
(if well field,one[at/long is sufficient) 22.Certification: �
N W a
Signature of Certified Well C naetor
�— Datu
6.1s(are)the well(s)oPermanent or Temporary
��� By signing this form.1 herelry certify that the xr/I(s)wac/were)co2rrrcted in accordance
7.Is this a repair to an existing well: 13Yes or o with 15A NCAC 02C.0100 or I.iANCAC 02C.0200 Well Construction Standards and that a
If•this is a repair,fill out know;well construction infor ///mation and e. lain the nature ofthe copy oflhis record has been provided to the well order.
repair under#21 remarks section or on the hack of thisfiar i. 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 130 ,S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple rvelk I&I all depths if different(t rumple-3[ia 200'and 2trcJ,1001 construction to the following:
40 10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level Lr above easing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (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
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Suaaly&Injection Wells: In addition to sending the form to
the address(es) 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016