GW1-2021-06334_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD tGW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague 14,WATER ZONES
FROM TO MCRTPTTO!l'
WellC'nmraeior Name q ft• )! lb ft. 15 G
B &K Well Drilling Inc i ?
SS o ft. 3 SS a.
N( Well CnntractorCertiiicatinn Number l5.OUTER CASING for d ti-casid!Yells)OR LINER'if.
livable
2857-A FROM - DtA7siETER TRIP NESS MATERIAL
0 ft, ft, a tt8 in. SOR-21 PVC
Company Namc
16:INNER CASING OR TLBING eethermat closed:loo
L Well Construction Permit 9: FROM TO ofAmeTER THICKNESS MATERIAL
List all applh able'veil ronsma:tion po,nut 6-1.3C".Cot nt.Stun,..Varm,,V.ere.i ft. ft, in.
3.Well Use(check well use): ft.
I L SCREEN
Wafer Supply'Well:
FROM TO DIAMETER I M.OT SIZE THICKNESS MATERIAL.
;Agricultural 01\4unicipal=Public h. ft. in.
Gcothctamal(HCating.Cooling Supply) [)Rcsitlential Water Supply(sinelc) in.
IndustrialiCotnmercial [DResidential Water Supply(shared) t& GROUT
_'Irrigation FROM I To MATERIAL EMPLACEMENT METHOD&..LMOLINT
Non-Water Supply Well:
\lonitorinu oRecovcry
injection Well:
ft. ft.
Aquifer Recharge r](iroundwater Remediation
19.SANDIGRAVEL PACK if a iicable
Aquifer Slordge and Reco%'erl' C)Saliniry Harrier FROM TO MATERIAL I Eh1PLACEMEVT n1ETHOD
3Aauifcr Test DStolmwarcr Drainage ft. ft.
Experimental Technology Subsidence Control ft. , it.
Cieo(hermalWlosedLoop) Tracer 20:DRILLING-LOG(attach additional.shee JInecessary
FROM TO DESCRIPTION color.hardness.soilirock w o. ruin size,cm)
Geothermal(Healing/CoolingRctunt) {)thee(explain under=2l Remarks) ft. S it
4.Date V4eil(s)Completed: Well ID# S fc. Xl: 11-
i
So.1}'01 Location: P y 0\ 11 �'� L L li tt G Y J�C4 C.
1..i ft. rt.
J-C—
� ft. ft.
Foe itityr(Jwnc Nanic ' 4i Facility W=Iifapplicable)
EC,LJ.1 L gl�� )-A l am),A . 4 Y� ft. ft.
--}+1'tfz.r
Physical Address.City. id Zi5t p ft. fr.
21.REMARKS t,r n l � i
K County Parcel Identification No.f PiN I Dli'WR Section
Sli.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(If u-eH ticid,one iaCiong is sufticieni) 22.Certifi- Ion,
N W
6.ISO re)the welt(s)ox Permanent or [:)Tempnrary S,nature of Certified Writ Cutttr�� — Datc
Br signing W irsm.I htrrhy ecrtiti•rhat the xrlllti seas(--ere)c&,micred in accordance
1.Is this a repair to an existing well: [)}'es or No !ith LsA AC.lC"02C.Oldt7 m 1.i4 CAC QC.0200;fill Currsiru,aiun Srandurds and ihui a
IfthLt it a repair,/ill nor knox,n x-ell con.ruvciinn ivija•niatian and r7pkim the nari,re of ihr roRi•of ihlt'recnrdhn:hCcn l:rnvlded to the x,Rl1 mrvur.
-pair under#21 romn•6's set-tion ar o n the hark ujthis form.
23.Site diagram or additional well details:
6.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pro%ide additional well site details or well
constriction,only I GW-I'i,needed. Indicate TOTAL NUMBER of wells cunslnntion detail;. You may also attach additional pages if necessary.
drilled: A / S119M1TTAi.INSTRUCTIONS
9.Total welt depth below land surface. �` (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple+relit liar all dr/nht itdili,ww iaratnple-3,iz'00 anti-Nii,100') constriction to the following:
10.Static water level below top of casing:40 (It.) Division of Water Resources.Information Processing Unit.
!,',rare,-ler'el is ahnr•e rasing,ne'-+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1/$ (in.) 24b. For h0ection Wells: in addition to sending the form to the address in'3a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12 Well construction method: constriction to the following:
ti.c,augur,rotary.cable,direct push.die.I I
Division of Water Resources.Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) o Method of test: Air Flow 24c.For Water Supply&Ini`ection Wells: lit addition to sending the form to
the address(es) above, also submit one copy of this tbrm within 30 days of
Chloe Tabs 2 Lbs completion of well construction {o the count health department of the county
13b.Disinfection type: Amount: 1 1 >' 1'
where constructed,
Form Gu'-I North Carolina Dcpaninem of Enviroamentat Quehiy•Division of Water Resonrecs Revised'_-2_-2010
a