GW1-2022-00232_Well Construction - GW1_20221216

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14.WATER7.ONES
Well Contractor Name FROM '10 ESCWPTION
2857-A R
ft. R
NC Well COVIOCur Cenifieitem\umber IS.OUTERCASING far add<eedwalks ORLINER B
B&K Well Drilling Inc FROM TU DIAMETER THICKVFSS MATERIAL
Company Name 0 fL I C45fL 1 61M In• I SOR-21 PVC
6, rr��T Qn' ^/ 16.DINER CASING OR TUOINC al closed-Impl
2.Well Construction Permit#: n( 2 - O ` $-S tT EOM TO DIAMETER Ti MATERIAL
L&I a/I applicable well rururru.aim/xrmits fi.e.U/C, nmty.Sralr. Variance.sm) O ft. R. f 1 t in.
3.Well Use(check well use): R R a.
we
Supply Well: 17.SCREEN
FROM TO DIAMETER MOTSIEE TNICKNESi MATF.RIAI.
Agricultural [3MunicipalNblic fit. R. I In.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) R ft. In
Industrial/Commercial QResidential Water Supply(shared)
10 GROUT
Inization FROM TO MATERIAL EMPLACEMENT NIETHOD&AMOUNT
Non-Water Supply Well: fL R
Monitoring Reetvery R. I.Injection Well:
Fit. ft..Aquifer Recharge [3Groundwatcr Remediation
Aquifer Storage and Recovery Salini Barrier m SAND/GRAVEL PACK a
ry FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. R
Experimental Technology aSubsidence Control R. IR
Geothermal(Closed loop) OTtencer 10.DRILLING LOG atfatY 2"6"skno If
PROM TO DKSCltuil]ON Ieeler, .euVreekN min do.eta.)
Geothermal Hea[in Coolin Return) Other(explain under#2lRemarks) O R S R
4.Date Well(s)Completed: /90 Z'�-iVeD ID# R• �jit
5 ell Locado H'
R R
Facility/Owner Nam Facility lD#(ifapplicablc) R• R
3) q1) R � rb�( W� ,f� z1). i-Itr1 R R
Poysial Address,City.and ZipR R DEC, i 1_ _
cl C�►1�1 ` 21.REMARKS I
+JI.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is suffid,n) 22.Certifrcatio •/'
N W - /
6.Is(are)the well(s)oPermanent or QTemporary Signature ofCcniflwd W5Killaracusir Date
Hv signing this form. I heretic crrto that be iu,110)woe(irm)constructed in accordance
7.Is this a repair to an existing well: E]Yes or Kith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Caeatruclion Standards and that a
/flhu is a repair,fill our knoxn well cnrurrudion infrumaiin an splain the nature ofibe ropy of thir record has kern provided m the xrll ouster.
repay under#21 remarks section or on the back 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 G -I 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: �[ )F S (R) 24a. For All Wells: Submit this form within 30 days of completion of well
pnr se.1 ip/e wear lisr all depths tfdigerenr(example-3@200'acid 2@l00') construction to the following:
10.Static water level below rap of casing:40 (D.) Division of Water Resources,Information Processing Unit,
/fnorcr level is above rasing.use`+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection 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
li Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push.Rc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
Chbr Tabs 112 tDa the address(es) above, also submit one copy of this form within 30 days of
fec 13b.Disintion type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I Nonh Carolina Department of Emlronmentzl Quality-Division of Water Rcsourta Revised 2-22-2016