GW1-2021-05487_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-Ii For internal use only:
. r.
1.Well Contractor Information:
—Robert Teague 114,WATER ZONES
\Veil Contractor Name FRONT To DESCRIPTION
B&K Well Drilling Inc )6 )
:�ii<ft. 3 —)- ft. � e 1
NC Weil�('oniTactorCeiiiiicatiL�t)Ntimbei S_
.0 lie*ble)
S g TER EASING(for ffirult.1-casird iv�*.el�2ORLir4ER(ifiapp_ JT o
285��T'A _F (7 t DAEMETER XNESS MATERIAL
61/8 SOR-21 PVC
Comparly Nano
16.INNER CASING 04R TUBING(geetbermal closed4oev)
2,Well Construction Permit 9: FROM TO DIAMETER I THICKNESS MATERIAL
N.Vt 111l,dPPIiCUbIC W&I C011SIMOV.11 PCII"M 6.0.I!l< k:0111111,State,lruriurc e.etej
3.Weil Use(check well use): ft. ft. in.
A 7,SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural niMuniciladir'Public ft. ft. IM
Gcothennal(I feat ing,'Cooling Supply) Sidcritial Water Supply(sim:)C)
ft.
- I -
IndusirialiCommercial &Rlsidenlial Water Supph.(Shared)
118.GROUT
irrigation FROM TO MATERIAL FAIP1,ACEMENT MFTHOD&.A.MOLTNT
Non-Water Supply Well:
7][Monitorm, ORecovery fL ft.
Injection Well: ft. ft,
7)Aqtl!'J[er Recharge nGroundwater Remediation 19;SANDIGX4LVEL PACK(if anialks ble)
pit, Stoulge and Recovery [)Saliniry Barrier FROM TO MATERIAL I EMPLACEMENTME11101)
Aquifer Test D-Stol-watcr Drainage
Experimental Technology 0Subsidence Control ft. fr.
:1(Jebthermal(Closed Loop) D Tracer 20;DRILLING LG.G.fattach additionalstutieti;ifnmary)
FROM TO DESCRIPTION ceolDr.kardbas.solFrock type.gni.size."C)
7),Geothertnal(Fleating/Coofing Return) E)Oflter("plain tinder 421 Remarks) it. ft. - 1--\
4,Date Well(s)Completed: 1 ft Well ID# ft. Y"
Focil4tlOwner Name facility ID",(Ir applicable) ft. ft.
rL ft.
�2
Physij zil Address.City.and Zip
2L REALARKS
County Parcel ldefllification No.t PIN
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ir�cll bald.one lavlong issufricient) 22.C�ztific2t!
W
6.ls(are)the welt(s)o Permanent or [37femporary Sistmutrc of Ceniticd Well Contracts D.t,
3)sinning thisfeimr,I cerfiti than thic rll!,i ,as 1.'C'r)cowimered in aceo'dwicr
7.Is this a repair to an existing well: Yes , No .\it ith 15.1 C.4C 02C ,12�.011)0o, 15C.4(02C.11200 141 Comtruaiun Standards and thwo
It rhir is a reliair.fill nia bio-r%-ell i-..1,9*,,,)1aio the nariov nfthe c oj{roffbis rccn4 ha+i1ccii prnvided to,the vctl otriter.
Nq tion w qo rise harkrat thisforin. 23.Site diagram or additional well details:
You may use the back of this page it,pro%ide additional cell site details or cell
S.For Geoprobe/DP'I*or Closed-Loop Geothermal Wells hai ing the same
cons(
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
niction detail;. `t'ou may alsoatta ch additional pages ifnecessary.
I..
drillcd- SUBNJITTAL INSTRUCTIONS
9,Tptal i-vell depth 0054 land surface. (ft-) 24,. For All Wells: Submit this form %viihio M days of completion of well
constniction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources.Information Processing Unit,
Vate,Ir,el is ah-ve casiq& 1617 Mail Service Center,Raleigh,NC 27699-1617
e diameter: 61
11.Borehole 18 (in.) 24b.For Iniection Wells: In addition to sending the form to the addicss in 243
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:
Ire.auger,rotary.cable,direct posit.etc-)
Division of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service tenter,Raleigh,NC 27699-1636
'i Air Flow 24c. For Water Su pply&Initc tion Wells: bi addition to sending the fonn to
1321:.'Vield(gpm) Method of test. the address(cs) above, also submit one copy of this form within 30 days of
Chlor Tabs 1 1/2 Lbs
13N Disinfection type: Amount: completion of well construction Ita the cotinty health department of the county
Form CIA'-I Nosh Carolina Department ofEmironinewal Quality-Division of Rater Resourc�s Revised 2-2-7-2016