GW1-2021-05420_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD (GW-1) For internal use Only:
I.well Contractor Information:
Robert Teague 14.WAT13RZo*rr
FROM TO OE.SCRIPTION!
Well Contractor Name O� 1• ft. fr.
B&K Well Drilling Inc t•OCOtieOD 9U ft. rt.
NC Well Contractor Cemlicanon Numbn 'C t r3jv, dLP��C�jCl. ts.pUTER CASQN0 for iatttta c" r*Qlls f?R'L#!3 if•` ieabte
Z8J7-A FROM DLiMETER THICKNESS MATERIAL
p ft. ft- 61ta ta' SOR-21 PVC
Company Nanic
lb:INNER CASING>t3R'Z:L$!NG eet6eimafclased-loe
FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permitin.
List ull applicable well eansrmcutin per,nins/i.o.UIC'.Cbu,m.Starr.Variance.etr.t
ft. ft. rn.
3.Well Use(check well use):
Water Supply Well: FaoM TO 01ANt ETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)MunicipaUPublic tL R. in.
Geothermal(iieatinglCooliug Supply) C)Rciidcntial Water Supply(single) ri. ft. In.
industriaVCommercial oResidentia(Water Supply(Shared) i8:GRUi)T
FROM TO M iTERLAL ENtpLACENIENT NMTHOD B AMOUNT
Irrigation
ft. iL
Non-Water Supply Well:
Monitoring, �Recocel}' ft. R.
Injection Well: ft. ft.
Aquifer Recharge [3CiroundwaterRemediatiolt 14:SANDlGR4wELPACK ifa licabtei
lAquifer Siordge and Recovery Salinity Barrier FRONI To NI.ATERL4t EMPLACEMENT METHOD
Aquifer Test [3Stormwatcr Drainage ft' ft-
Experimental Technology Subsidence Control
{seotharmalIl']osedLoop) Tracer 20.DRILf1NGliOG'(attacltaddiiitinelslteets:ifaecei9y.
FRO"
TO DESCRIPTION rotor,ha est so,troek it c. rains-vc etc}
Geothermal(Ffieating/Coolin Return) Other(ex lain under a21 Remarks) ft. ft. ) ri
G'
p q—
4.Date Well(S)Com feted: d_L y}'el4ID# C
ft. It.
5a.Well Locati mar
ft. ft.
Facility 1D=life livable) ft. fL
Facility/Owner Name y Pp
ft. ft.
ft, ft.
Physical Address.City.and Zip
21.RENIARKS
rnr�r��c�e, i
County Parcel identification No.tPlNi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latflone is suffieientt 22.Corti tin: }
Sr6iaturc of Certified Well Tontracitir '— Outc
6.Ware)the weit(s)(Permanent or 01femporary
Br signing this form.)herelm certiti that the nrllCu ma,tmrrel rnuanured in amocdan.F
7,is this a repair to an existing well 13 Yes or No rith 15A AC AC 02C.0140 ar Ii.4 vCAC o2C.0200 Tell Construction Srandardc cord that a
lr ,rhir,is a repair.Rll out kn0—well ennstnxtinn ill i nnarim, ,r crplain the nature n/'the
cop-ofihis recnrd has seer;prnvided to the melt mcner.
repair under m21 remarks section ern-on the bark 01 thi-..farm_ 23.Site diagram or additional well details:
b.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional Hell site details or welt
construction details. you may,also attach additional pages if necessary.
construction,onlyIGW-l is needed. Indicate TOTAL NUMBER of wells
drilled: — SSU,BM11'rAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All—Welts: Submit this form within 30 days of completion of-:11
For nrulriple+c'elA list all depths if diff mjn rcrample-3:_1_00'and?Ca;100') construction to the following:
I0.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
1f a fter lFvel is ahnre Casing,use +.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/$ (in.) 24b.For Injection Wells: ]it addition to sending 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:
fi.e.auger,rotary.cable,direct push,etc.)
Division of Water Resources,underground injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test Air Flow 2 Ic.For Vt`ater SuDDIv&I�iection Wells: In addition to sending the faun to
13a.Yield(gpm) the address(es) above, also submit one copy of this form whthin 30 days of
Chlor Tabs ,Amount- 1 112 tbs completion of welt construction; to the county health department of the county
tab.Disinfection type: wher4 consnvctcd. C
Fonn C.K'-1
North Carolina Department of Environtnenial Quality-Division of Water Resources Revised_-?'•2016
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