GW1-2021-05725_Well Construction - GW1_20210706

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
g
Robert Tea ue kt.;RSYTERZONES
FROM TO DESCRTPTION
Well Contractor dame ft_
B &K Well Drilling Inc �UL
r� - ft � ft
NC Well Contractor Certification Number `]r Of 8SIC1�Un re
t O,ti10f1 O 1<<' ir"fER CASII�u'G - .iiinttrc <ivelh UK>LtNER�il'.8 [cnhlel
2857-A Inf0frr p��Z c�ECtOlt FROM TO DIAMETER THICKNESS MATERIAL
V D ft. ft. 61B tn• SDR-21 PVC
Company Name
16::1Ni4ERfA (3RTk1$1NG: eeFAerd[af::elused foo ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable v-ell consnuction permiu/i.e,U/C.Cotalm.Stare.Variance,etc.) f[. ft. in.
3.Well Use(check well use): in.
Vater Supply Well: LR:SC;TtEEN -I - A
PPY FUnI TO DIAMETER SWTCIZE THICKNESS MATERIAL
ericultural [3Municipal,Public ft ft. in.
Gcothennal(14cating/Cot4ing Supply) [DResidential Water Suppiv(singlcl ft ft. in.
lndustriaUCorrim)ercialResidantial Water Supply(shared) ►8'6ROUT. :'<
Irrigation FROM TO bIATERL[L EMPLACEMENT METHOD&.h,MOLNT
Non-Water Supply Well: ft. ft.
hlonitorin DRecovery
injection Well: ft. ft.
Aquifer Recharge OCroundwater Remediation
19i'5rtNU/EItAYJ L 0i1CK.ff Wtile)
Aquifer Storage and Reco,ery C)Salinity Barrier FROM TO MATERLAL EMFLAc£�1evr MEl tt!1D
PAquifcr Test [DStolmwaicr Drainage
Experimental Technology Subsidence Control ft fc.
Geothermal(Closed loop) OlTracer 20 DRILLIM31043 attach adGifieiialslteetsi£'uecessa
FROM TO DESCRIPTION. (color-hardness.soiUrock is e. ra[nsize,cte)
Geothermal(Heating/Cooling Return) Other(ex lain under T21 Remarks) R: SL tt.
t .4 _ L
- rt.
4.Date Well(s)Completed:�.1l_-'Ll Well ID# k S 1 (J 1�_
j ft. ft.
sq. 11 Lo anon: — —
rt. XV
rt.
acility/ wnerNamo' 1 Facility IDfr(ifaoJp�►(i/q�blef)
1411,14-1 kA
t ft ft
Physic Ad
fal dress,City.and Zip
;21s REMARKS;::r ;
vl C ej &
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field•one ladlong is sufficient) 22.
N W
6.ls(are)the well(s)oPermanent or Temporary Sigualurc of Cenificd VAII Contractor Date
3r signing this forin. 1 here(,)ccrtifp that the writ(s)seas fmv-c)consmicred i,:accordance
7.Is this a repair to an existing well: Yes or !V*to lid,1 SA NCAC 02C.01110 ur!iA NCAC 02C.0200 Well Construction Standara's and that u
Ifthis is o repair,fill nia blown well cnnstniction information anife7plain the nanu'c oftine cope of this record has necn provided to the'tell osvrcr.
repair andrr 421 remark;section w'vn the back of this./arm. 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 deta:Is or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well dept3t'below land surface: \�1 > _(ft) ZJa. For All Wells: Submit this form within 30 days of compleb,a of well
For multiple ue/ls lire all depths ifditferent(:rainple-JfeiV 00 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 tvarer level is above casing,use— 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Tniection Wells: In addition.to wilding the form to the adoress 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,rolaiy,cable,direct pusL etc.)
Division of Water Resources,Underground Injection Control Program..
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Iniection Wells: hi addition to sending Ltie fbim to
the address(es) above, also subunit one copy of this form within 31) days of
Chlor Tabs /2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type: Amount: whe r I
re consnvctal. �
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resource i Reel;a1 2-22-2016