GW1-2021-06360_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
0
Robert Teague 14.WATER ZO..IFS
TO
\Yell C'ontraetor Name FROM DEGCRrPTiONt it.
B & K Well Drilling Inc i'
ft. ft.
NC'Well Contractor Certification Numbcl 15.OUTER CASING(for:molti-cased-wells)ARLINE9-0f:" licable-::i
2857-A FROM I TO DLiMETER THICI:lyESS MAZERtAL
a It. ft. 118 i 1°- SDR-2t PVC
Company Nmnc �
16.INNER CASING OR TUBING eetdermal closedsloe
2.Well Construction Permit#• FROM TO I DIAMETER THICKNESS MATERIAL
List u!t upOtiiphtC++r11 rintsnucriurt permit,ti.c.t'IC.(:urnrn.Saar,t'uriurrcr.err.1
ft. ft. in.
3.Well Use(check well use): ft. ft. in,
Water Supply Well; 17.SCREEN
FROM TO DIAMETER S410TS12E THICKNESS MATERIAL
Agricultural .Municipal Public ft. ft. in-
Geothermai(Heat ing,Cooling Supply) Residential Water Supply(singlc) in-
lndustrialr'Cornmercial LJResidential Water Suppiv(shared) 18 GROUT
Irri ation FRopt I To MATMkI. EMPLACEMENT METHOD x.AMOLT1T
Non-Water Supply Well: ft. ft.
llonitorirg ORecotcry ft. ft.
injeetion Well:
ft. ft.
Aquifer Recharge rl,roundwater Remediation
19,5ANl}1GR-4YEI,PACK if applicable)
=. . .
Aquifer Sulydge and Recovery oSiliniry I1atTier FROM TO DLATERIAL EMPLACEMENT METHOD
A4uifcT Test []Stonnwatcr Drainage It. ft.
13 periniental Technology Subsidence Control ft. ft.
Geothermal(ClosedLoop) 13Tracer 20:DRILLING LOG(attach addonanal.sheets i€necessary)
FROM TO DESCRIPTION enlor,hardness•sail.*mck n•c. in size,ctcl
Geothertnal(Heating(Heating/Cooling Return) f7titer(explain tinder t2 i Remarks) p� ft. ft.
4.Date'tiell(s)Completed: -}' Well ID# �J ft, ft.
Ifle—
ft. ft. 711
5a.Well Location:
1hr 1�r� ft. ft.
Fa lity'OwnerName FaclhtyID=Iifa+plicable)
Physical Address,City.and Zip
L,I, cC�*tom'fJ 1h 21.REnfaRKS
Coulity Parcel rdewiiication No.(PIN} •+r' Ux�t
5b•'Latitude and longitude in degrees/ntinui eslsecunds or decimal degrees:
lit visit tictd.one iat:�!ons;is;ufficitntt 22.Certiftcatia
ri tti' �n'
v
6.ls(are)the well(s)0 Permanent or [31'empnrary Slutunnc ofCcnificd Wolf G>nnacu r Datc
it, sierrnrz this!orta 1 hot-elr:eerti6,that the xvttty,vas r-,ere)cnnsin+cred in accordance
7,Is this a repair to an existing well: [:)Y es or Nn !ddr!;a?C.IC•02C.0100 Q, 15.4 AC.aC 02C.0200 gi 11 Cunsrruciiun Standard.+and their a
i!this+is a repair,Tll rat knonvr n'e11 cnn+Ynri ones i,tJnrmaliar and cgrlu;n nc�nauv,•n/rhr rope r%(this mcnrd lrav been jrrnvidt'd to the xe1l nu�te'r.
repair render=?1 rrusa•ri.:s+z'tion urz'n the i"u-4 of thia-ha-m. -
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells hating the same You may use the back of this page to prat idc additional'A ell site details of.,ell
construction,only I GW-i'is needed. Indicate TOTAL NUMBER of wells cunstnlction details. Z'au nlay also attach additional pages if necessary.
drilled: A St1BMIT1 A(.INSTRUCTIONS
9.T.otal well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
FnrtmuGip!r u•e17a lest all drptrs fdifG'rvnr lexample-�:_i'011 artd_'lit ltltl'1 canstn!ction to the following:
10.Static water level below top of casing:40 (ft.) DiNision of Water Resources.Information Processing Unit,
l/+caner level is ahnrc;rr.wrrs,.us.•-a- 1617 Mail Service Center,;Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.j 24b.For infection Wells: in addition to sending the fornl to the address in 14a
Air Rotary above.also submit one copy of this form within 30 days of completion of well
12.Well construction method: constriction to die following:
t i.e.auger,rotary,cable.direct push.etc.) `
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONi,V: 1636 Mail Service Center,Raleigh,NC 27699-1636
139.Vield(gpm)-�N Method of test: Air Flow 24c. For Water Supply &infection Wells: bI addition to sending the fonn to
the address(cs) above. also submit one:ctipy of this torn within 30 days of
Chlor Tabs 1 112 Lbs completion of well consiructioit to the corm health department of the count
lib.Disinfection type: Amount: whcrc consnuctcd. 1 Y
I
Form COX-1 North Carolina Depamnew of Envinuutienial Quality•Division of Crater Re,oti'rces Revised'_-22.2016
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