GW1-2021-05426_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD 1G�� g.. JFternaluSe
Only:
1.Well Contractor Information: ' n 1pL\ s
G� J Robert Teague n R ZONES
��G TO DESCRIPTION
I Contractor Name
`Bl&K Well Drilling Inc fNC Well Contractor Certification Number RCA_SING 04'TRM'cased Wells OR 1,1114ER+f teableY
2857-A FROM To- D41ME7ER THICKNESS MATERIAL
ft p . v ft. 61/8 ia' SDR-21 PVC
Company Name 16.INNER CASING ORTLIBIPIG est�ermnlclosed=l
2,Well Construction Permit#: 9 7�S FROM TO DIAMETER THICKNESS MATERIAL
List all applicable--ell Caestntrtiun permits/i.e.C'/('.(.'ounn•. tuie,Variance,eu.)
f[. ft. in.
f[. ft. in.
3.Well Use(check well use):
Water Supply Well: FROhI TO DIAMETER I SLUT SIZE LTHICKNESS MATERIAL
'Agricultural E)Municipat-Public ft. R. in.
Geothermal(1lcating;C001ing Supply) IARcsidcmial Water Supply(single) ft. ft, in.
Industrial/Commercial Re dential Water Supply(shared) 18'GROUT
Irrigation FROM TO NIATERLAL _ ENtPLACEM£NT METHOD&AMOUNT
Non-Water Supply Well: ft. tt.
Monitoring [DRecoeen' ft• ft.
injection Well: ft. ft.
Aquifer Recharge E)6roundwater Remediation
m SAND/GRAVEL PACK' f applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO 11.ATERLAL EMPLACEMlNTAIETHOD
Aquifer Test C)Stonnwatcr Drainage
Experimental Technology 0SUbsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 2®:DRILLING LOGYattachaddlMenelsheets iLneeesa
FROM TO DESCRIPTION color,hardness.son4oek tr c. min svc,cue)
Geothermal(Heating/(:ooling Return) r.30ther(explain under#21 Remarks)
ft. ( t
I 1 K'G
4,Date Well(s)Completed:
a,WellID# ) + ft.
t. ft.
5a.Well Location: ft. 8 10 CAA
�S S v
it. ft.
FacilityiOwner Name Facility 1Dc iitapplicable)
ft. ft.
ft. ft.
Physical Address.City.and Zi
21.REMARKS: .
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latllong is sufficient) 21/./Ce I tlon:
StgnaturcofCcnificdWcllC tractor -D.ttc
6.1s(are)the well(s)oPermanent or OTemparar}
Br si4nntg this/ono. I hemins rerti}j�rear the nrilfd[.'as.tuerc)cmt,rnrcted in accordance
7.Is this a repair to an existing well: 13Yes or n !ith 15.4�C.4C 02C'.01 dd ur 15.4 NC.4C 02C.02fi0 well Cunsiructiun Standards and that n
ropy o%ihis reenrd has hcen prnvided to the urll ouva•r.
11 this is a repair.fill out knon•n Fell mn.clntciion in%nrmotinn and explain the naturC g%the
repair undo-�21 rrnatrfc aertiun ur on the:',ark u%this/)rm. 23.Site diagram or additional well details:
b.For Geoprobe,'DPT or Closed-Loop Geothermal Wells hating the same You may use the back of this page llo provide additional well site details m well
construction,only I GW-1 is needed. Indicate TOTAL N UMBER of wells
cunstnncnon details. You may also attach additional pages if necessary.
drilled: j� SUBMITTAL INSTRUCTIONS
9.Total well depth below'land surface: 70 IS (ft-) 24a. For All Wells: Submit this,form within 30 days of completion of welt
Fnr nadtiple u•e/!.a(i.ar all depd�s i%diJlerem n:rantple-:�<%'tl�'and_'%a'y100') construction to the following:
40
10.Static water level below top of casing: (ft.) DiNision of Water Resources,Information Processing Unit,
1%%voter level is abnre casingo,use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
t 1.Borehole diameter: 6 118 (in.) 24b.For infection Wells: in addition to:ending 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 following:
(i.e.auger,rotary.cable,direct push,e[c.l
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the fonn to
the addresS(CS) above, also submit one copy of this fonn within 30 days of
Chlor Tabs Amount: 1 1/2 Lbs completion of well construction t I the county health department of the county
13b.Disinfection type: when;constructed-
Form GW-I North Carolina Departmentof EnvironmentalQuality-Division of water Resources
Revised 2-22-2016
i