GW1-2021-06363_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well!Contractor Information:
Robert Teague 14.WATER ZONES 4
FRO%I TO DESCRrP ION
Well Contractor Name ft. t ft.
6&K Well Drilling Inc ft, ft.
N( 15.OUTER CASING(for
ti-E-ed 'tfs)
2857-A I FROM TS. M­1_T.R 1A111A1
ft- Ln It- I5 v8 i i
Company Name -I-Aft I&INNER CASING OR 7UHING(IreetheT of cldiw400p)
L Well Construction Permit Cl FROM 3 FROM I TO I DIAMETER _I THICKNESS MATERIAL
Lmr,dl applicable�-ell-wm...ction pet-,na Ii.c.17(*.(.'otmn%Sraie.*)-tunce.cre.) ft. rt. in.
3.Weil Use(check well use): fu ft. I..
47�.SCREEV
Water.Supply
Supply Well: FROM TO DIAMETER. NLOTSIZE—-THICKNESSM.ATFRI AL
DAgritultural IDMunicipal-Public ft.
DGcottlicimal(HcalingiCouling Supply) Residential Water Supply
ft. ft.
lindustriaKornmercial 0RSidenLial Water Supplv(shared}
18.GROUT
_11rriggation FROM I To MATFRI&L EMPLACEMENT NIFTHOID&AMOUNT
Non-Water Supply Well: ft, ft.
73moniturim ORecovery ft. ft.
Injection Well: ft. ft.
:)Aquiller Recharge 13(houndwater Remediation 19,SANDIGRAV9L PACK(if applicable)
QAqu i fer Slot a nd R ecox ery [)Safiiiiry Barrier FRMI TO -MATERIAL EMPLACEMENT METHOD
:t,Aqui1`cr Test [)Stormwater Drainage ft. ft.
:]Cxperiniental Technology
OSubsidence Control ft. ft.
36cothermal(Closed Loop) 131 racer 20.DRILLING LOG fattach addiltilline1sheetsif necessary)
l
FRONI I to I)F-'CRIPTION(mlD�.harditaNssoiL* ktvl!c,gmhi size,etc))Geothermal(Heal ingtCooling Rcturn) [30ther(explain under.421 Remarks) 16 ft. 6
ey fit.
4.Date Well(s)Completed.;��_ Well ID# CA 9-4 12
5a.Well Location.-
-LAC 10C 5�x& IL
Facility ID= I'applicable) ft.
Facility,'Owner Nan ft. ft. N
Physical Address.City.and Zip it. ft.
MARKS ij r_-7;
21.RE.
Parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well ficid,one latilon�4sufficicno 22.Certific2tio
W
6.14(a.re)the well(s)opermanent or [3Ternporarq il Daw
4, $, thi,.fiwm.I herrltY rent 6�that the xr/lftl ivat(uvre)rnminicred in acoi-dancr
7.Is r this a repair to an existing welt: Yes �-o/n.n0his rerniV bar been prnvidelo Iith].;_4 AC N)C.0100,fir1.5A A CAC 02C 100 wcll Cumtruction Standards and that
d, the�cll oititer.
it rhtt i,a fill nur known K-el/con5intennn ipti6rinat"" the notlov
repair imh,i-#21 ivww-k,sr<Yicrr urol,the bai k ell this fonl. 23.Site diagram or additional well details:
You may use the back of this page to pro\ide additional well site details or ,ell
con$tniction,only I Ci� is needed. indicate TOTAL NUMBER8.For Geoprobe!DPT or Closed-Loop Geothermal Wells hat in
the same consmiction details. }'au ma)al I so attach additional pages if necessary.
con$tniction,only I CiW-I is needed- indicate TOTAL INUMBER of wells
drilled:_ SUBMITTAI.INSTRUCTIONS
9.'Total well depth bclov%land surface: lk--) S (ft-) 24a. For All WC115: Submit this foral within 30 day., of completion of well
Fir nwhiple wells list alidell(hSit'diffi,rent texample-3,'J'00'ond c -iniction to the followin^
on.,
10.Static water level below top of casing:40 (ft.) Division of Water Resources.Information Processing Unit.
if,vurer level is above casing.use- 1617 Mail Service Center,Raleigh,NC 27699-1617
I L'.8oreholediamete- 6 1/8
24b. For fniection Wells- in addition to sending the form to the address in 24a
Air Rotary above. al.,,u submit one copy of this form within 30 days of completion of well
12.,Well construction method: construction to the following:
J ix,.:augel.rotary.cable.dircet push.ctc.)
Division of Water Resource,s,Underground Injection Control Program,
FOR WATF RSUPPLY WELLS ONLY: 16-16 Mail Service Center,Raleigh,INC 27699-1636
Wel s: hi addition to sending the fonn to
13a.Yield(gp-) Method of test: Air Flow 24c.For Water Supply&Injection
the addTeSS(eS) above, also so brnit one,copy of this tbrm within 30 days of
13b.Disinfection type: Chlor Tabs Amount: '112 Lbs completion of well construction to the county health department of the county
where constructed.
Fenn C,,A*-I Nonli Carolina Deparnnew of Environmental QuaNy-Division of Water Reso6rccs Revised 2-22-2016