GW1-2021-03490_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague :MWATERZONEq.
FROM TO DESCRIPTION
Well Contractor Name 75% /,< 6
�
B&K Well Drilling Inc 0 Lt-\
NC Well Contractor Certification NumberIn iskd::ivi11k0:0R:LfNBA4 a
2857-A FROM T Qlti�k if
I DIAMETER. THICKNESS MATERIAL
0 ft. 6 1/8 In- SDR-21 PVC
Company Name
2.Well Construction Permit#: FRO I TO_ DIAMETER THICKNESS MATERIAL__
k- -A LM .
Lis applicablc.*ell colisinycLioll permits(i.e.UIC(;Out in,.Stale, Variance,etc:) ft. in
3.Well Use(check well use): rt. ft. in.
Water Supply Well; FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
,Agricultural unicipal/Public ft ft. in.,
:3Gcotherinal(ReatinglCooling Supply) BResidcnEial Water Supply(single) fit ft. in.:
31ndustriaucommercial E)Residenuall Water Supply(shared) M.
hIrrigation FROM TO NIATEPUL EMPLACEMENT METHOD&.0110ITN'r
Non-Water Supply Well: ft. ft.
Monitoring []Recovery I ft. ft.
I injection Well: ft. ft.
QAquifer Recharge E]Groundwater Remediation I9:,SAN*DXAAVEL:PXCK:t!f licablo:
J I app
Aquifer Storage and Recovery [)Salinity Barrier FROM TO INLATERUL­ EMPLACEMENT NiErHOD
Aquifer Test C)StormwaEcr Drainage ft. ft.
Expefirriental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Traeer
FROM TO DESCRIPTION(color.han1pess.sofl/mck type.grain size,cm)
Geothermal(Heating/Cooling Return) nOther(explain under.,"21 Remarks) S fit. 0 )*r4 ch
4.Date Well(s)Completed: well ID# 5 ft-
ft. ft.
Sa.Well Location:
Factlitylbx6er Name Facility ID4'(if applicable) ft. ft.
ft- ft.
�sieal
q ft.Address.City,aaid Zip
r) )n
County Parcel Identification No.(PIN) md''vR sec"1011
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cert 47ft
N W
6.Ware)the well(s)oPermanent or [3Temparary SipwurcofCertified Well Contracto Datu
As signing this(own.I hereby certify,their the xr/11.0 was tu-crc)consimcied it,accordance
7.Is this a repair to an existing well- lye r)snoti o iir)i No �iith 15,4 NCAC 02C.01470 u;lj,4.AjC.4C 1)2C.0200 W,.Il Celastruction Standards and their it
((this is a repair,fill our known well consiiiicii�!Pinfn explair,the nature of the copy o.fihis recni-al has been provided to the veil owner.
repairunder#21 renitrrks section oi-on the backofthis.larin. 23.Site diagram or additional well.detaits:
S.For l Geoprobe/DPT or Closed-Loop Geothermal Wells havine,the same You may use the back of this page to provide additional well site details or well
constmction,only
constniction details. You may also attach additional pages if necessary.
C,
drilled: W-
I is needed. Indicate TOTAL NUMBER-of wells SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v y (fit-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple well kv all derpths if.differeni(krainple- (A200'and 2@100')
construction to the following:
10.Static water level below top of casing:40 (ft-) Division of Water Resources.Information Processing Unit,
weiter level be above casing,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
12.Well construction method: construction to Elie following:
I i.e.auger,rotary,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&Infection Wells: In addition to sending the form to
the address(es) above, also submitlone copy, of this form within 10 days of
13b.Disinfection type: Chlor Tabs Amount: '112 Lbs compietion of well consrruccion to the county health department of the county
where constructcd.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revisec.2-22-2016