GW1-2021-05700_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD(GW-11 For Internal use Only:
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I.well Contractor Information:
Robert Teague 14.WATER ZONES
FROM TO DE,SCRfPTW
tVe!I Conrracror Nat e
B & K Well Drilling Inc EGG rt. 7 fTt.
ft. n.
NCl6 ell ConnaclorCernficationTJumbtr IC OUTER CASING OwwoUieaxd'aelh t?RLLN1iA if'
2857-A FROM TO DLfMETER TH[Cti1SESS1�TERIAL
0 ft. I •ft. 5118 in• SOR 21 PVC
Company Naatc
j )�� 16.ii r ER 1NG IUDING refhematrlaetd-
2.well Construction Permit#: r—y✓ i �� FROM TO DIAMETER THICKNESS MATERIAL
Cb:all applicable aa'ell cons.rntcnot penaav(i.e.UIC C'ou,tnt Sra[e. Variance,el") ft. ft. tn.
3.Well Use(check well use): ft. ft. m•
Rater Supply tL ell: I7 SCVFEN
FROM TO ' MANIETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMtmicipaUPublic ft fL in.
Gcothcrnal(Meating,Cooling Supply) Residcntial Water Supply(single) ft !'.. in.
industrial/Comnrercial [3Residential Water Supply(shared) tg;GROUT
Irri anon FROT.1 To— nL1TERIAL EyfPLACEMENT METHOD,L.-LMOIRiT
Non-Water Supply Well:
iilonitoring Recovery h. ft.
Injection Well:
ft. ft.
C:%quifer Recharge [Groundwater Remediation
19.SAN&GR4VEL PACK(if applicable)
rlAquiferStordge and Recotery [3SalinityBatrier FROM I TO I MATERIAL EMPLACEMENTMETHOD
nAquifcr Test [3Stotmwatcr Drainage
Experimental Technology [3Subsidence Control
Cieothemial(Closed Loop) Tracer 20.DRILLING LOG attachadditionelsbeetaitneeess
FROM To DESCRIPTION color,ha ees.WbrVCR n rate size,etc.)
Geotherma(Heatin�_iCoolin_g Return) Other(explain under=21 Remarks) ft � tl
( �'. ,
4.Date well(s)Completed+s �' Well ID# Cl ft.
5a.Well Location: b-,C'„5tt. ��5 rt. r, .
Facibrr,Owner.4ame t - Facility ID4 hf Tiicable) ft. ft,
Physical Address.City.and Zip
rt, tt. JUL 0 u 2021
County Parcel ldcu(ificationNo.IPIN) Information Processing Unit
e^.Ilon
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(f wcll field.one Iatllone is sufficient) 22.Cel'tiflcRion• _.,.
N W
6,Is(are)the well(s)OX Permanent or 13Temporary S14•114lurc of Ccnificd wcti mtractor Data:
By caning Chia form. I here!r)crrlift-that the xrlllt)waa(uere)crawntcied in accordance
7.Is this a repair to an existing well: QYes or No -,illy 15,4:bC4C 02c.0100 err 13A V'CdC 02C.02fi0 well Conirructiun StondarJ3 and Jun a
!/'[hrc i.t a repair:Tll aut knoN'n hell fnn.tUuenaR•nJnnttannn a**ndd�:plarn trc nauur n1 the Copt.record loss been provided to die yell neuter.
t eprrlr«rtdr'r 7�I rr•nerrk>ir<?;.n err am the bnel•uJ thi,.fvnn.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells has ing the same You may use:lie back of this page to provide additional well site details or well
constriction.only 1 GW-I is needed. indicate TOTAL NUMBER of wells constntetion details. N'ou may also attach additional pages ifnecessary.
drilled: _ SUBNIIT'fAl,INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit rhis form within 30 day, of completion of well
Fri,t w1uple Inc all drpth.s ifdfrerew taromple-_(¢�011�and? Illl1') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources.Information Processing Unit.
it tearer level is ahoar Caving,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 118 (in.) 24b.For infection Wells: 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 completion of well
12.Well construction method: construction to the followin,:
C.auger,rotary,cable.direct push.etc! -
DiOsion of Water Resources,Underground injection Control Prugram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm} S li Method of test: Air Flow Z4c. For Water Supply&Injection Wells: L1 addition to sending the foi n to
the address(cs) above, in also submit one copy of this form within 30 days of
13b.Disinfection type: Chloe Tabs Amount: "/z lbs completion of well construction to the county health d"rtiment of&.e county
where consnuctcd.
Form 15,11V-I North Carolina Department of EnViromnental Quality•Division of Water Resources Revised 2-232016