GW1-2021-03499_Well Construction - GW1_20210607

C5-1.91r.1.,! ........
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague MW.ATERzoNES
FROM TO DE,SCRTPTTON
Well Contractor Name �,�� },7 ft
B & K Well Drilling Inc s C
ft, ft.
NC Wei I Contractor Certification Number IX''OUTERCAS11NG tiietti-easednel ©RhI:NEItlea ' -
2857-A FROM TO DIAMETER THICKNESS MATERIAL
ft. 5 118 in. SDR-21 PVC
Company Name
16.:1NiVER'4C:$5IN6 t3R:E1'i>SfP1G:"eetgetmai.cfused!oe
1- `J 2.Well Construction Permit#: [ `1 V' - o FROM I TO I DIAMETER I THICKNESS I MATERIAL
Lisr till appiicable Hell coasmiction.permin li.e.UIC.6 urn State.Variance,etc.) ft. k. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM7tEEw
FRUM TU . DIANI ETER St, TCIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Rcsidcn[ial Water Supply(single) ft 1t in.
lndusuiaUCommercialU.Residential Water Supply(shared) I GROtT
irrigation I FROM TO NL'kTERLIL ENTPL.ACEMENT NIETHOD&.V%IOLTNr
Nun-Water Supply Well: ft.
Monitoring DRecovery ft. ft.
injection Well:
R. ft.
Aquifer Recharge Groundwater Remediation 9;SaivfNRVEf PA-K-W il luiitite
Aquifer Stor9ge and Recovery C)Saliniry Barrier FROM To 1%L4TERLAL EMPLACEME—NT METHOD
Aquifer Test []Stormwatcr Drainage ft. ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 2®:OBIT LIAiGI UG attaclsddiNotiel<'slaeetv►Ettecess
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) I FHOM To DESCRIPTION color,ha tq,softl ocl,t. in size,cte)
.1 ft. rt• cJ
4.Date Well(s)Completed: S1 Well ID# L
52.Well Location: ft-
Faciliry/Owner Name Facility lD:(ifapplicable) ft. ft. ap;
l ft. ft. �.
Physical Aikiizss,City,and Zip ft. ft. 1 1
tHg f11
County Parcel idtntificwttion To.(PiN) p, f^..rrQvS
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �Y
(if well field,one ladlone is sufficient) 22.Cer
7
W
6.Is(are)the well(s)Ox Permanent or Temporary Si aiaturc"f Ccnificd well C.mtr ar Datc
At signing this(orm.1 hereLv certify that the nr/lls)was(xrre)consmicred in accordance
7.Is this a repair to an existing well: DYes or No with l.iA NCAC 02C.0100 ur 15A 2VCAC 02C.0200;Yell Cunstruction Standards and that a
!f this is a repair,ill out biown well ennstruetion information and Z•.rplain the nature of the ropy of this recnrd has been provided to the Fell owaer.
repair under 21 remarks section ur un the nark of this fwtn.
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 Nell site details or well
construction,only I(.'TW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: rr SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �b (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ur./is 1w all depths ifd)jerrni(aroinple-3C4,200 and_'0a)l00'1 construction to the following:
10.Static water level below top of casing:40 Division of Water Resources,Information Processing Unit,
)f enter level a abewe casing,vse.._ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6118 (in.) tab.For iniection Wells: In addition to satding 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 the following:
1 i.e.auger,rotary,table,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&IniectionI Wells: In addition to sending the form to
the address(es) above, also submit one copy,of this form within 30 days of
Chlor Tabs 1 1)2 Lbs completion of well construction to the corm health department of the count
13b.Disinfection type: Amount: i �, y
where consnitcted.
I
Farm GW-1 North Carolina Department of Environmental Quality-Di>ision of Water Resources Revisea 2-22-2016