GW1-2021-03495_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD (GW-1 For internal Use Only:
1.Well Contractor Information:
MWA717RZONES
Robert Teague
FROM TO DESCRIPTION
Well Contractor Name I.S! ft. ft- I ("
B & K Well Drilling Inc 2 ft ub
NC Well Contractor Certification Number
MtJ
I i4i6d®ilb)OR'h1 -lp
2857-A FROM T % 31AMETER THICKNESS MArewnL
0 6118 in. SOR-21 PVC
Company Namc
16.INNER:
I I I THICKNESS MATERIAL
2.Well Construction Permit#: 'S�)W FROM To CIAMETER
list(111 applicable mell co)IrrrucrionPermin Variance,ere.) ft. ft. in.
in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE; THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. n,
:)Gcothennal(Heating/Cooling Supply) Presidential Water Supply(single) ft.
Ind ustrialiCommercia I [)Residential Water Supply(shared) lsy GRom ........
Irrigation FROM ft. TO NIATERLAL EMPLACEMENT METHOD&ALMOUNT
Non-Water Supply Well:
DMonitoring n Recovery ft. ft.
Injection Well: ft. ft.
nAquifer Recharge [3(-jro.ndwater Reinediation
T_ SANDiGR_4VJM.:Y.4,C ......
Aquifer Storage and Recovery [3Saliniry Barrier FROM I TO _T NIATERIA.L EMPLACEMFNT.IETHOD
9—tAquifer Test [3StonnwaLcr Drainage
Oki PExpenmantal Technology OSubsidence Control ft.
tit
Geothermal l0osed Loop) [)Tracer .20.DRILLING 10( attail'addtPROM DESCRIPTION jo
To RIPTION(c,olop4todriess.stntIrmktI)C, rain Size.etc)
nGeothermal(H lain under#'21 Remarks)J - tt ft. A-
4.Date W'eli(s)Completed: Cf ---I-Fell ID4
fay)
5a.Well Location:
ft.
FacilityiOwnerName facility ID4(if applicable) E U
ft. ft.
ft. JUN X 720
City,mud Zip
Processing Unit
County Parcel identification No.(PIN) ETTY R
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wtil field,one lat/lone is Sufficient) 22.Cer icati
N -W
Sid�L latuo,J C.c­e rlilficd Wcll Contractor Date
6.Is(a.re)the well(s)operltoanerit or E)Temporary
Bs signing this loan.I herely-certify that the 111rll(.$)tvat twere)commicica'in accordance
7.is this a repair to an existing well: [3yes or 1ANo with 15A NCAC 02C.0140 or lj,4.NCAC 02C.0200 well Construction Standards and that,)
lfthis is a repair,fill o?tr known well canstrucrion inf—malion and'.'Pl gin thc native of the coky of this record has heen provided to the Ncll oAv7wr.
repair under p 7lr(!oj111-Ay section uroo the back of thi..turn
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe,'DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 25 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .--(ft-) 24a. For All Wells: Submit this form within 30 days of completive of well
Fm multiple welt,JLq all depths ffdfflerrnt t&arnple- ;(2,200'and 2@100*) constniction to the following.
10.Static water level below top of casing: 40 (ft.) Di-Osiort of Water Resources,Information Processing Unit,
)(rater level is above Casing.we 1617 Mail Service Cen'ter,Raleigh,NC 27699-1617
1
11.Borehole diamet,.,. 6 /8 (in.) 24b.For infection Wells: In addition to sending the form to the address 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:
(i.e.auger,rotary.cable,direct pusl,-etc..)
Division of Water Resources,Underground Injection Control Program,
FOR*ATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Air Flow 24c.For Water Supply&lniectio.� Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: . — the address(es) above, also submit one copy of this fbnn within 30 days of
/2 Lbs 1h :co "
Chlor Tabs t. e health department of the county
13b.Disinfection type: Amount: completion of well construction to unty
Where constiliacd.
Form CYN&'-I North Carolina Department of Environmental Quality-Division of Water Resources Revist,'2-22.2016