GW1--03582_Well Construction - GW1_20230522

WELL CONSTRUCTION RECORD
For Internal Use Only:
L Well Contractor Information:
Robert Teague
We11 Contractor Name 14.WATER ZOO;`:
FROM LO
sz
2857-A DESCRIPTION ft. f[. i
L .
NC Well Contractor Certification Number f[• x ft
B&K Well Drilling Inc 15i°OUTERCASING toriuolti'. apd. ORLttVElt i£""ticable FROM TU DIAMETER THICKNESS MATERIAL
Company Name 0 ft ft. '
61/8 in. SDR-21 PVC
2.Well Construction Permit INNER'GASING OR TUBING eotiefirtal.ttosed
List all applicable well construction permits(t.e.UIC,Conn FROM TO DIAMETER THICKNESSx
County,Slate.Variance,etc.) ft f4 in. MATERIAL
3.Well Use(check well use):
ft. ft.
Water Supply_Well:
Agricultural 0Municipal/Public FROM TO DIAMETER SLOTSIZE THICKNESS, MATERIAL
Geothermal(Heating/CoolingSupply) ft ft• in
PP Y) Residential Water Supply(single)
lndUstrial/ComIDeICial Residential Water Supply 1 (shared) ft
ft' in.
Irri ation 1&'GROUT
Non-Water Supply Well: eltont TO MATERIAL EMPLACEMENT METHOD&4MOONT
Monitoring ft• ft
Injection Well: Recovery
ft. ft.
Aquifer Recharge Groundwater Rcmcdiation
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK if a cattle
Aquifer Test FROM TO[3Stormwater Drainage MATERIAL EMPLACEMEPIT�fETHOD
ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer ft' ft.
Geothermal
20.DRILLING LOG,attach additioualsheets if ne
(Hearin Coolin Return) Other(explain under T21 Remarks) FROM i To ft. DESCRIPTION(color.h Hess so,Urack h e ram size eta) +j
ft. /
4.Date Well(s)Completed:a-d�'a� S !
WeI1ID1r ft. ft.
52.Well Location: t[. fL
rJ d So C
Faerlity/Owner Name r" / '�y ,. ,^ "`
Facility ID#(ifapplicable) '1
3 ft ft ....,..,.'c�...4..i t6..•.a �
A 7LI r>Yr,t 1 / II ft. ft. MAY 2 2 2023
Physical Address City,and Zip
ft. ft.
r
1 2112E -
MARKS'?' t t
County
Parcel Identification No.(PIN) a�u•_
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is suffrcicnt)
22.Certi on•
N W i
6.Is(are)the well(s)oPermanent or oTernporary �-ignaturcofCcrnncd WOLICOntractor Date
7.Is this a repair to an existing well: Yes or No By.signing this form,1 herehv certify that the welt(v)It-ac(were)constructed in accordance
IJthis is a repair,fill out known well construction formation Tplain the nature of die copy of th 15.4 Crec C d has be 0 pr 15.4
w d d to h 02C.0200 rYef!Construction Standards and that a
repair under#21 remarks section or on the back ofthis 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 I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 3l—1 `� SUBMITTAL INSTRUCTIONS
For multiple wells list all depths/fdifferent(example-3@200'and 2@100') (ff') 24a. For All Wells: Submit this fort within 30 days of completion of well
10.Static water level below top of casing:40 construction to the following:,
lfwater level is above casing,use +•• ft) Division of Water Resources,Information Processing Unit,
6 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Injecton 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:
FOR WATER SUPPLY WELLS ONLY.• Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
l
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply'&Injection Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs 1 112 Lbs the address(es) above. also submit o
Amount: n copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016