GW1-2021-06284_Well Construction - GW1_20210915

WELL CONSTRUC,TiON RECORD(GW-1.1 For internal Use Only
1.Well Contractor Information:
Robert Teague 14,WATER ZONES
FRO?I Tn DESCRIPTION
Wellcomt.etor Name
B &K Well Drilling Inc C-Q r.eg`+� ' S a GLloa
NC Well Contractor Certification Number C�rJ�,
O` !� Z)v 15.OUTER CASING for multi-cased weIN OR LINER`it ieabk
2857-A `Cy` FROM TO D[1METER TxICt:NESS MATERIAL
Wit\,, Otl
p ft. ]� f[. c t!a ia. SDR-21 PVC
Company Nanic 5 N� INNERCASIAIGOAT1B1 rmddosed-
2.Well Construction Permit fr`: b FROM TO I DIAMETER THICKNESS MATERIAL
lnr,dl appit,able.'ell,opismacon pe•rmuc el.c.t'1(.t'ounn.Sru,e.Mariana•.ere l ft. ft. I in.
3.Well Use(check well use): ft. ft' in.
17.SCREEN
Water Supply Well: FROM TO DIAMET& 1ZI.0T SIZE THICKNESS I MATERIAL
Agriculturnl .� ]Municipal Public H. ft. in.
Geothermal(Hcating.Cooling Supply)!E—_Re;idcnlial Water Supply(single) ft. rt, is
indUStri3l/C0IIlnrefLia1 Residential Water Supp}v(shared) 18.GROUT - -
Irrigation FROM To N(ATPRLAL EMPLACEMENT NIF.TROD&AMOLN'T
Nun-Water Supply Well: ft. ft.
?vfonituring ®Recover ft. ft.
injection Well:
ft. h.
aquifer Rechar;_e ]Groundwater Remediation
19.SANDlGRaVEL PACK(if applicable)
0.Aquifer Sturdge and Recovery DSahiliry Barrier FROM To I MATERIAL EMPLACEME?T alf.T HOD
Aquifer Test DStonnwatcr Drainage k. ft.
Experimental Technology DSUbsidence Control ft. ft.
Geothermal(Closed Loop) ID(racer 29.DRILLING LOG(attach additional sheets if necessary
Geothermal(HeatingiCooling Retum) nother(explain under 421 Remarks) FROM TO DESCRIPTION color.karcipr%s,soil rock gVe.ervis Size,etC1
��]
4.Date Wells)Completdi-3 Well Ill# C) ff. f,.
52.Well Location: ft. ft.
Facility =niapphcablel ft. f[.
yr P- L t� 1 ft. ft.
Physical Addr+css.City.and Zip ft. ft.
c.�; yes 21.RE 1iARxs
YV-
County Parcef identification No.(PIN)
5b.Latitude and longitude in degrees/minutxs/seconds or decimal degrees: - —
(ifwcll field,one lavlonc iS sufficienn 22.Ce t i of
N W 12 1
6.1s(are)the well(s)ox Permanent or Temporary Si(_n,:,turc of Ccrtiticd Wit C',ntracu,r Date
A, signi„g thi,inrn,. 1 hrrrhnr eertili'that the.,11W corn(.-ere)cnnarmcird in ice dancr
7.Is this a repair to an existing well 0l es or `o th?�A<<'.tC f)ZC 01JJ ar 1 i.4 vCd("JZC.fQIX)Hel!Cunsrruoriwt SlanJarJs and rhat n
it fhu is a repair,fill oar kno%,t.,-I/cnaa:nieni ryortnarinn d c.rplain the nature nl ih: cnpr of ihi.,recnrd has horn provided to the ur11 mmur.
repair under 021 ronark,s,,Wit ur•un the hark of this fount.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells ha,in-,the same You may use the back of this page to provide additional well site details or well
construction,only GW-I is needed. Indicate TOTAL NUMBER of wells cunslnicnon detail:. You May also attach additional pages if necessary.
drilled: SUBMITTAL.INSTRUMONS
9.Total well depth below land surface. 'p,G (ft-) 24a. For All Wells: Submit this form within 30 days of completion of welt
rn,uur/dple r!!.a lim all delvhs it difl•rrru terample-+_i'of) and Zip;l0f)'i construction to the following:
10.Static water level below top of casing:40 Division of Water Resources,Information Processing Unit.
l/nurerle,rl roc alnrr;n.aing.nsr" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
Air Rotary above.also submit one cupy of this font,within 30 days of completion of well
12.Well construction method: constntction to the following:
1 i.e.auger,rotary.cattle.direct push.tic.t
Division of Water Resources.Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: Air Flow 24c. For Water Supply&(niection Wells: b,addition to sending the fonn to
the address(es) above, also submit one ropy of this thnn within 30 days of
13b.Disinfection type: Chlor Tabs Amount: r V2 Lbs completion of well construction to the county health department of the county
where constructed.
Form Gbv-I North Carolina Department of Eri ironnirnial Quali-v•Division of water Resources Revised 2-22-201 n