GW1-2021-05489_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW For Internal Use
1.Well Contractor Information:
Robert Teague
14,WATER ZONT-S
Well Contractor Name FRO'NI I ft. I DESCRrPTION
B &K Well Drilling Inc TL_5`r17G I 1 1)elf 0,
ft. n.
NC Well Contractor Cenification Number <)Z
—15.—OUTER C_
ASING(tiar'stitfi-icasid. olh)'OR L]NtR4& Jew:
2857-A FROM TO i DIAMETER I THICKNESS�RVTTERJAL
L I
Company Nanic 0 ft- 511a , in' I SDR-21 PVC
G f0eallbef—d!Oiin"1­1
I THICKNESS MATERIAL
2.Well Construction Permit FROM TO DIAMETER 3 7/-7 160 INNER CASING OR TVBIr64
lisl,dl applicuble,,'ell consing.-rio)i permits Ii.e.Ul(.Coulon%Stule.Variunce,ow.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '::MSCIREEN :...6:
FROMTo DIAMETER SLOTSIH THICKNESS
MATERIAL
Agricultural [DMunicipaLiPublic ft ft. in.,
Geothermal(I feat i n,-,'Cool ing Supply) Residential Water Supply(single)
ft. ft. in.
Ind ustrialiCommercia I Residential Water Supply(Shared)
:18.GROUT 7
Irrigation FROM To NIATERLA.L
"PLACEMENT%rFTHOD&AM0[7NT
Non-Water Supply Well: ft.
3NIonitorin,, []Recover)- ft. ft.
Injection Well:
7)Aquifer Recharge []Groundwater Reinedialion ft. ft.
.19:SAND/GR4KEL t ACK s littiible}
Aquifer Stor9ge and Recovery oSalinity Barrier FROM TO AlATMAL —EMPLACEMENTMETHOD_
AquifcT Test ostormwater DTairim-,c ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .20;13RILLING-L-OG:(ittkhaddi4i"gi:.sheeb:jf.aftemiry).
_FROM TO OF-SCRIPTION(color.he grain We,etc)
Eqwl.softtrock M30.
Geothermal(Heating/Coolinj;Return) Other(explain under.421 Remarks) ft. 165ft. eo C1)A
4.Date Well(s)Completed: --2,6- Well ID#5
5a.A`ell Location: ft. ft.
ft. ft.
Facility/ wrier Name Facility ID;;(Ifa, 1* abl ft. ft.
.11)
C'�S's C) ,f j2d ft Ne, ft. ft.
Physical Address.City.and Zip ft. fr.
C, bc, "-RE"'
County Parcel Idenlific4ition No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one laulong is sufficient) 22.Certifica
N -W
CA
6.ls(are)the well(s)OPermanent or E)Temporary StgDate
41 qenintz thisfiorin.I here!,:cerft6e that the xr/ks)was(urrc)c­.,,nicied in acco,dance
7,Is this a repair to an existing well: QYers or No tith]5,4.-�(.4CO2C.011)0,��-IS.4!VC.4Cr)2C.020014ellConsn-uc:tiuiiSi(indeirds,,tidih,il,,
lf'thm is a repair.ill ow knomi%-ell ennsiniciinn inionnatinn And V l ain the nature&I the t-oln-ofihis receird has been prnvided to the x ell owwr.
repetir i6mdrr 421 remarks section ur on the hark 01*1his.form.
23.Site diagram or additional well(details:
S.For Geoprobe,'DFT or Closed-Loop Geothermal Wells hawing the same You may use the back of this page to pro ide additional well site details or well
construction,only I GW I is needed. Indicate TOTAL NUMBER of wells constniction details. You may also attach additional pages if necessary.
drilled: ✓ ——", A SUB.N1111"I'AL INSTRUCTIONS
9.Total well depth below land surface: o-6 24a. For All Wells: Submit this form within 30 days of completion of well
Fnrawltiple,wils li,talldel,flis irfdrfiivrent —
constniction to the following:
10.Static water level below top of casing:40 Division of Water Resource&Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: 6 118 (in.) 24b.For-Iniection Wells: In addition to sending the fonn to the address in 24a
12.Well construction method: Air Rotary above.also submit one copy of this fern)within 30 days of completion of well
construction to die following:
(i.e.auger,rotary.cable.direct PUSIL Cie.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Vield(gpm) Method of test: Air Flow 24c. For Water Supply&Iniectio Wells: In addition to sending the Conn to
13b.Disinfection type. Chloe Tabs Amount: 1 1/2 Lbs the address(es) above, also submit one copy of this torn within 30 days of
completion of well construction to the cotuity health department of the county
where constructed. I
Form GNk-I North Carolina Depamnent of Environmental Quality-Division of Water Resources i Revised 2-22-2016