GW1-2021-05723_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD(,GW-1} For Internal Use Only:
1.Well Contractor Information:
Robert Teague la:waxeRzos;.> .
FROM TO DE,CR TTON
Well Contractor Name
6&K Well Drilling inc
J L,• ft. � tt. �y�
NC well Contractor Certification Number 1i'OUTER=CAS1Nt;` innllrcesed tveli3 E>R if Geable
2857-A FROM TTO^� DIAMETER THICKNESS MATERIAL
D ft ` ft. b eta in. SDR 21 PVC
Company Name, j , 16''INNER.JvkS4NG'tJR:Fi113tNG ee1�aE tatddsEd ititi
2.Well Construction Permit# r FROM I TO I DIAMETER I THICKNESS I MATERIAL
1,4t all applicable veil consavcdon permits it a UIC Cbunnt Suire.Variance,ere,.) ft. I In.
3.Well Use(check well use):
1?'i$CtEEtY'>
Water Supply Well:
ETER y .MATERIALAgricultural �MunicipallPublic FROM It. TO DIAM ft. in. WTSIZE THICKNESS M
Gcothernal(Heating(Cooling Supply) 2csidcntial Water Supply(single) tt it. in.
IndustrialiCommercial C)Residential Water Supply(shared)
Irrigation FROM TO MATE RSAL EhIPLACEMENTNIETHOD&.AMOCrIT7
Nun-Water Supply Well: fL ft.
Monitoring DRecov-ery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Retnediation
d�3:5A1+Df>sRAkFf.f'!AGK. 'ti�abfe}
(IAquifer Stor#ge and Recovery DSaliniry Barrier FROM TO MATERIAL I EMPLACEKE.Y'T METHOD
Aquifcr Test [)Stonnwatcr Drainacc ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 2@.<13f2T1111VGt OG:stthe$addi 1} oitetsheefs£f ueixsf'
Geothermal(HeaTing/Cooling Return) other(explain under 921 Remarks) FROM TO DESCRIPTION coror nara�c,s savnocl n a 7n sixc.Me)
� ft. S ft. i J
4.Date Well(s)Completed: Z:J( Well ID# S ft." ft. (
5a.Well L cation: ft. r ft. i_
f /l
./��^tt t(� P ` "(`,�t y L--- C. fL �t riL''
IC:na Yl. A�L�L �
Facility/Owner Name Facility IDC(if applicable) 0 ft. 3 ft. /
Physical Address.City.and Zip Lu } — I ft. ft
J' �1 y6�/9`16 t it? 5-� 21:RF:11#ilRit: ((��
Cou ty + Parcel identification Nt=.(PIN) 2"2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one ladlong is sufficient} 22.Certifrca rM3 ion
[)vtVR Seci;cn
N w f
6.Is(are)the well(s):�Ix,Permanent or OTemporary r gear of Ccnifttd Wcll G aeux Date
St,,r,'Sning this form.I hercl?v certify that the xell(s)war'ixcrej consmtered in accordance,
?.Is this a repair to an existing well: Yes or Na ,ith I5A NC.tC 02C.0100 up-1 5.9 NCAC 02C.0200 Well Construction Standards and that 1)/J'thLk is o repair,fill oru kt:own well cnnstruciion infornmtion an crptain the nature of the cops of this record has been provided to the%ell owner.
rrr/xrir ander r21 remarks section or on rite bark of this fvrnn. '
23.Site diagram or additional well details:
b 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 W=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: G (ft-) 249. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple welk list all depths ifdijferent{sample-.Cm200 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 narer level tt ahm•e casing,use-� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 18 (in.) 24b.For Injection Wells: Inladdition io sanding the form to the address in 24a
Air Rotary above.also subunit 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.) j
Division of Water Resources,Underground injection Contra)Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servi!ce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&c I Lotion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within SO days of
43b.Disinfection type: Chlor Tabs Amount: 1 1t2 Lbs completion of well constructil n to the:county health department of the county
where constructed.
Form OW 1 North Carolina Department of Environmental Quality-Division of Water Resources Revised'-.22.2016