GW1-2021-03493_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) Fol Internal Use Only:
I.Well Contractor Information:
Robert Teague wThR TO DEscxrP l TTON
Well Contractor Name
ft. ft.
B&K Well Drilling Inc rt u
is
taeitt cased ivelis t)R i If�FE4t if's' '
NC Well Contractor Certification Number 1�:OUTER EASING ``
2857-A FROM TO DLIMETER THICKNESS MATERIAL
p ft. ft. 6118 ! in' SDR-21 PVC
Company Namc t ,:
• r b FROM R( 1 GUR FI OIAM. e'etLesmakelICKNES
2.WQII Construction Permit#' w_'I y FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well caurrtction permits fi.e.UIC.Counm.State.Variance,etc.) ft. ft. In.
ft. fL in.
3.Well Use(check well use):
Water Supply Well: FROMCRE£h
I TO OIAaIETER ,I SLOT SIZE THICKNESS MATERIAL
Agricultural [3Mrnicipal/Public ft. ft. in.
Gcothennal(Heating Cooling Supply) 1�t`csidcntial Water Supply(single) fL tL m
_''lndustriauComniercial esidential Water Supply(Shared)
Irrigation FROM TO hL-tTERLAL EMPLACEMENT bfETHOD&.A.MOINT
Nun-Water Supply Well, n. ft.
Monitoring Recovery ft. ft.
Injection Well: ft.
Aquifer Recharge Groundwater Retnediation
19:$AiND/SRAw:1 L PACK it A "'ticiiblel
Aquifer Stor2ge and Recovery [3Saliniry Barrier FROM TO 3I stTERIAL EMPLACEMENTDIETHOD
Aquifer Tcst DStormwatcr Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTracer 26:DRILLING jt3t;atich,adGNoiglslieetsif.uecessa
fit Ohl TO DESCRIPTION(color.hardnt L soll? _k t a nn stm stc)
Geothermal(Heating/Cooling Return) Other(explain under R2l Remarks) R. Cft.
4.Date Well(s)Completed:SC- Well ID# O ft. tt.
i
5a.Well Locati n:
ft. 46 ft. k L Lit>
\yw it
rFacility/Owner Name Facility ID (if applicable) ft. ft.
ft. ft.
Physical Address.City,and Zip
ZI.RF.1►LARK$ ,. .. ,, ...
County Parcel Identification No.I PIN)
Drnm
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SSlfi V111t
(if well field,one Iaulong is sufficitnl) 22.Certification, DWR 8ec.on
Stsatu�tt�JWcllC�mtracorc � Date
6.ls(are)the well(s) x Permanent or �Te.mporary
Br signing this form.I herciw cer!ily that the xrlks)ivat lx•crc)cotutnsted in accordance
7.Is this a repair to an existing well: [)Yes or No with 15A NC4C 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
f(his is a vepau-Jill rim broxw well comimciion information an rplan the natw-e of the copy of this record has been provided to the tell o%vtwr.
repair under R21 remarks;section ur on the back of iht's.furm.
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
construction,only GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
.drilled: SUSh11TTAL INSTRUCTIONS
9.Totai well depth below land surface: S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr nwlttple ncelk Itsr all depths ifdijfereni(&anp/e-.(a 200'and 2@100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources.Information Processing Unit.
IJ'narer level is above casing, ese•'-" 1617 Mail Service.Center,Raleigh,NC 27699-1617
6 1/8
11.Borehole diameter. (in.) 24b.For infection Wells: in addition to sending the form to the add-css in 24a
above,also submit one copy of this form within 30 days of completion of well
.12.Well construction method: Air Rotary construction to the following:
Ii.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 Suably&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:
Chlor Tabs 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed. j
Form GW-I North Carolina Department of Environmental Quality-Division of water Ressmrces4 Reoiscd 2-22-2016
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