GW1-2021-03498_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) [F�iAtemal Use Only:
1.well Contractor Information:
..........
Robert Teague
14:w;h R:zoly s .. ...........
....;
FROM TO DESCRIPTION
\Veil Contractor Name t, ft.
B&K Well Drilling Inc ft ��rc a
o l G
NC Well Contractor Certification Number c OUTER:C $INC; uiaift " "'#el Q1t ;lt�FEIY `
2857-A FROM TO DIAMETER THICKNESS MATERIAL
p ft. ft. 61/B in. SDR-21 PVC
Company Namc
L 1G:li�N�IYGA511�tG f)R'F!9$ttVY" QeEtaelkttlaf:cued-lbo :?:.. ;..<:
2.Well Construttion Permit#:1'(l R n C) y FROM I TO DIAMETER I THICKNESS MATERIAL
•List all applicable well construction permits(f.e.UIC C:ommt Stare, Variance,aced ft. ft. in.
3.Well Use(check well use): in.
Water Supply Well
PP Y : FROM TO DIAMETER SWTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft.
Gcothennal(Acating/Cooling Supply) Residential Water Supply(single) ft ft• in :
Industrial/Commercial Residential Water Supply(shared) ;
i
irrigation FROM TO NIATERL&L EMPLACEMENT METHOD&.sMOUNT
Non-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft.
Injection Well:
Aquifer Recharge []Groundwaier Remediation
:19 SRNfNBRAY�L`1'4GIS Gt' ).cable '
Aquifer Stor#ge and Recovery [3SalinityBarrier FROM TO DL-MRL41, EMPLACEME`tTAIETHOD
Aquifer Test [3Stormwarcr Drainage ft. ft.
nExperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 29 DRIISEING#OC attseli.sdditttinalislceefs.R:iieeess
FROM TO DESCRIPTION(color, s,sonic k R °earn Sim Cie.)
Geothermal(HeatinJCooling Return) Other(explain under#21 Remarks) �+y tt. ft. `
4,Date Well(s)Completed-5 - 1 Well iD#
ft S ft. ar
5a.Weil Location: 33 n
IiAn�a t 1h �VG�;h USft- rc. �� a �� `�'
fr.
Facility/Owner Name i 1 Facility lDK(if applicable)
ft.
S\ I r \�lJ ft. ft. � d� '
Physical Address,City,and Zip ft. ft.
am
Zi
County Parcel Identification No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ilut „
i31(if well field,one lat/long is sufficient) 22. ertificatiion: �lvP�t$ QG,Oft
N W
6.Is(are)the wetl(s)opermanent or DTemporary Siltnaiuri,of Certified Well Con' •tor Date
By signing this/onn.1 herelry certify that the xrll/.t)wac(x•ere)coarrrzicted in accordance
7.Is this a repair to an existing well: Dyes or ONo +rith 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards rind that a
U'this is a repair•Jill out knomvi well ennttruciion injonnation and explain the nature of the cop)'of this record has peen provided to the melt owner.
repair under X21 remarks section or on the bark of this.larm. 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 I GW-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also anach.additional pages if necessary.
drilled: _1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:} S (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For niultiple cells 1w all depflu it different(sample-3(@200'and 3@100') constriction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
•ll'ivater level a alnve casing,4ce-+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 {in-) 24b.For Iniection Wells: in addition to striding 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:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Siail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gptn) Method of test: Air Row 24c.For Water SunuIv&Iniection\i'ells: In addition to sending the folvt to
the address(es) above, also submif one copy of this form within 31) days of
13b.Disinfection type: Chlor Tabs Amount: t 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
22,
Form GR'-1 North Carolina Department of Environmental Quality-Division of Water Resources �, Revised:__-_Oho