GW1-2021-06654_Well Construction - GW1_20210706

t Q
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Robert Teague i ::w.aT>R:zoral s
FROMTO DESCRTPTTON ,
Well Contractor Name ,
B&K Well Drilling Inc n /��1 D. 1 S , rt
Lj
NC Well Contractor Certification Number J v� © I ,
Unit 'S".0uTE1LGi$1N"G far.esialtti ed-ivel DR3lt9>sit il":s'
2857-A (�ipC @BS►n�Unit FROM TO DIAMETER THICKNESS MATERIAL
ni P-SlaJ�, 0 ft ft. 61/8 to SOR-21 PVC
Company Name ��v� lb INNFRC:SINGf3R'F#lBtPiG. eelgetmat clo3ed-!oo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lis(all applicable Nell cotesrrucuon permits(i.e.1JIC•.C:ounn,.State.Variance,etc) ft. ft. in.
ft. �.
3.Well Use(check well use): f[. in.
17i$C7tEElY'...:
Water Supply Well: FRONT I TU I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural E)MunicipaUPublic ft- I.
Geothermal Mcating/Cooling Supply) E)Rcsidcnrial Water Supply(Single)
lndustriaUCommercial [)Residential Water Supply(shared)
iGRQUf .
Irrigation FROM TO M.ATERLAL EMPLACEMENT NIETHOD&A.MOU!NT
Non-Water Supply Well:
,Monitoring DRecovery (i. ft.
injection Well:
Aquifer Recharge E)Groundwater Remediation
193h1Vfl1ERAWEL PAGK::{if a licetile) Y ^.
Aquifer Storage and Recovery Salinity Barrier FROM I To NLATERLAL EMPLACEMENT NIETHOD
Aquifer Test E)Stormwatcr Drainacc ft. ft.
Experimental Technology Subsidence Control ft. tc-
Geothermal(Closed Loop) OTracer 28:D.RILL1NGisOG pttacl additiviisl(sloeebif
FROM I TO DESCRIPTION color,ha ess.so(Froel.tive.grain size,eta)
Geothermal(HeatinJCooline Return) r3Other(explain under fill Remarks) ff
4.Date Well(s)Completed.. ' I Well ID# fI. l tt. >✓ -�4/-s H t
- 5a.Well Location: �
it. ft.
Facility/Owner Name „1 Facility ME(if applicable)
I ft. ft.
13 ( 6l�t� 5'rn ��
Physical Address,City.and Zip
1
21 1tE1HARK.S:;::
1 i Y)l f r 1 l• f\
County Parcel identification No.(PIN)'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,out lat/IOnc is sufficient) 22.C;;:,rifi9h � C
N W
itmaturc of Ccmifted W• ontractur Datu
6.Is(are)the well(s)OPermanent or Temporary���((( 13y.signing this form.1 hereiry crrtrfy that the xrlks)Ivan(x•ere)cnastntcred in accordance
7.Is this a repair to an existing well: E)Yes a. No n ith 15A XCAC 02C.0100 ur 1 jA.tr'CAC 02C.0200 well Construction Standards and that u
If(hth is a repair,ill out knoxw well construction infonnatio a, No
the nature of lire cops'of this recni d has heen provided to the well owner.
repair under 421 remarks section or on the bark of this(urn. 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
constnuction,only I CW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: LL SUBMITTAL INSTRUCTIONS
9.Total well dept glow land surface: 7 �-J `d ___-(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fm multiple wells list all depths ifdi(fetent(arample-3Q200 and 2 ct,100') construction to the following:
10.Static water level below top of casing.40 (ft.) DiNision of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 21b.For Tniection 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: constnuction to ate following:
(i.e.auger•rosary.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 Supply&Iniection Wells: In addition to sending the fonn to
the add ess(es) above, also submit one copy of this form within 30 days of
Chlor Tabs t 1/2 Lbs completion of well constructiou tv the county health department of the county
13b.Disinfection type: Amount:
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised'_-21--'_016
i
i I