GW1-2021-03396_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague RECEN 14:W;1TERzoN1s
ft. rt. / ,
FROM TO DESCRIPTION
WzllContractorNamz � � � ��w� (�
B&K Well Drilling Inc �(� / . !
• ft ft
NC Well Contractor Certification Number r Ca�rj�rE(J Unit
11itOCC`;C�tlQl1[�fQ.. 15.'OU'PE1LCtiSlivG ain1L-cased:ivel OR:i:11�R 1F'` ,l+eahle ;
2857-A ��rdl►��gCY'Oli FROM TO DIAMETER THICKNESS MATERIAL
t} ft. ft 6 SJ8 ; fiDR•2t PVC
Con pony Name ^�/ f4.� L/ 1&INNERG tSllttG�A.�U�i1rIG est�crmat clo3ed-toe
2.Well Construction Permit#L t 1 �7 l7 FROM I TQ I DIAMETER I THICKNESS I MATERIAL
List rut/applicable well conrimc ton permits(i.e.WC Counm.State.Variance,err.) ft. •ft. in,
3.Weli Use(check well use): ft- e. in.
Water Supply Well: I rSt°RE£h
FROaI TO DIAMETER SLOT SIZE• THICKNESS MATERIAL"
Agricultural C)Muns"cipaYPublic fL ft. iR:
Geothermal(Heating Cooling Supply) �esidcridal Water Supply(single) fL a +n
)Industrial/Commercial ]Xsidencial Water Supply(shared)
Irrigation FROM TO MATERIAL EMPI CEMENTA[ETHODBcAAfOItNT
Non-Water Supply Well:
:31klonitormg [DRecov'ery ft. ft.
Injection Well:
ft it.
Aquifer Recharge [)6roundwater Remediation
29.5i1nt7JTF.KA%EI,I'4C;K:tf "llc8bf8 ..
QIAquifer Storage and Recovery [3Salittiry Barrier FROM TO MATERLA.L I EMPLACEMENT METHOD
AquiferTest []StormwatcrDrainage fr. ft.
Experimental Technology Subsidence Control ft. ft.
(3eothermal(Closed Loop) Tracer 28 13RTI L1NG:I OG attaei aildenoilel sliee�s.rFi>ecessa
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To SCKIPTION Color,hardncc sotVrock ri fn size,Mt)
R. ft.
4,Date Well(s)Completed: Well ID# ;ft. e.
SP.Well Location: ft. ft.
,j a
FactlityiOwner Name Facility ID0(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft.
♦ 21�:RE1tiihItKS",
Ounty Parcel ldentific4mon No.(PIN) •,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lorty is sufficient) 22.Cer ca- n-
W - � �
6.ls(are)the well(s)opermanent or OTemporarti Platum ofccrtificd Well Contracof Date
3- signing tlat form. I hercfry certif}�that the wril(t)war emcrc)cottclntcred in,arordance
7.Is this a repair to an existing well: k.voli')n
s or No pith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!f this is a repair'fill out btoxw well canstmc a d No
the natu r of die col?'of rhir recur d ims free»provided to the xrtt Dort r.
repair tinder>21 remarks section or on thr hark of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use:he back of this page to provide additional well site details or well
constnuction,only GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary
drilled: �} SUBMITTAL INSTRUCTIONS
9.Total mvell d th below land surface: c7` : (ft,) 24a For All Wells. Submit this form within 30 days of completion of well
Fnr nwhiple it-ells list all deprlu ifdijferenr(example-_!(,200'and 2ca100'.) constnictien to the following:
10.Static water level below top of casing:¢� (ft.) Division of Water Resources.Information Processing Unit
If,rarer level i.c above casing,rice"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole d 6 118 III (in.) 24b.For iniection Weiss: 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 complet on 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 Mail Service;Center,Raleigh,NC 27699-1636
13a.Yield(gpm) vS� Method of test: Air Flow 24c.For Water Supply&injection Wells: In addition to sending tl,e form.to
the address(es) above, also 'submit one copy of this fonn within 30 days of
Chlor Tabs i 1/2 t� _ completion of well construction to the coon health department of 'me count
13b.Disinfection type: Amount: p' county P' y
where constructed.
Form OW1 North Carolina Department of Environmental Quality-Division of Water Resourc I s Revised=22-2016
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