GW1-2021-08143_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD (GW-I) For internal Use Only:
1.Well Contractor Information:
14:WATERZQNES
Robert Teague
FROM TO ESCRiP ON
Well Contractor Name - C ft. 7 S ft• TV)
B &K Well Drilling Inc ft. r rt•
.
NC Well Contractor Certification Number 1[::0[}fER'C5tS7NG fririttatti cased>weDsOIZL#!cIER'd
FROM DIAMETER TfIICKNESs M-47ERIAL
2857-A f1. ti ft. 6118 in, SOR-21 PVC
»:
mc lfi:<1h1VEHGASII�G E�;t`U81NG eet8eirmbtel
Company Na osed-lbe ;
FROM TO DIAMETER THICKNESS M.ATCRIAL
2.Well Construction Permit#: ft. I. in.
List all applicable Nell construction permits(i.e.UIC,COantY.Stare.Yardmtce,etc.l
ft. ft. in.
3.Well Use(check well use): j
ITi:SC3tEE1V<::
Water Supply Well' [3MunicipaL'Public FROM it TU DIAIs1ET ER in.. SLOT SIZE THICKNESS MATERIAL
Agricultural
ft.
esidcntial Water Su iv slc in.
Geothemal(Heating/Cooling Supply) PP, lSm- ) ft ft
hdusuial Commercial ORNsidential Water Supply(shared) �:. Rp
8,G TO NI.ITERUL EMPLACEMENT hIETHUD&.WdUt r
rAquifer
g, ft.
Non Wateruppl}°Well!
Recovery R. h.
ll. R. D.
charge �Groundwacer Remzdiation
19.19ANIN.GR VEL'Yt1GK:{tf hcsble)' EMPLACEMEyT METHOD
�Sahniry Barrier FROM TO 9L4TER14L
r2ge and Recovery ft ft
Aquifer Test [3Stormwa[cr Drainage
ft, ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 0
2®DRTIfLVGIOG attack�dditiiinelaheets.ifnecesa
FROM 7 DESCNIPTI N col -herdnas. iUrocA a tar S-ze,Mc))
Geothermal
Geothermal(Heatine/Coolin Return) rl Other(explain under#21 Remarks) rt. ft.
�� ft.
Well(s)
(j
4.Date ell(s)Completed: �~ Well ID#
ft. ft. r
5 Well Loca ion: ft. ft.
Y0 fr. ft.
Facility/)Owner Name e Facili 1D if applicable)
Z L/ l VM1%S (3, r ft. fL
ft. ft.
Physical Address,City,and Zip
%21<REi►fARKS
ConT Parcel Identification No.(PIN) om �ESSIN 1
County
5b.'Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certific Ira
(if well field,one latilong is sufficient) / C
N W
' ell
Date
6.,!s(are)the well(s) Permanent or �Tempmarv' Si ntaturc of Ccnihed Wct1 Contra
Bv signing this norm.1 liciel,v ccriinj'that the xrllla)wac!Mere)constructed in accordance
„'Ith 15A�'C'.iC 02C.0100 or I j.9 NCAC 02C.0200 Well Cumtructiun Standards and that a
7.Is this a repair to an existing well: Yes or*nsplain
No cops'onihis record has hcen provided to the well oirner.
Inthia is a repair,fill out brown well construction injnrmatin the nature onthe
I-epnir undo-421 remarks section ur un the back o(this/arm. 23.Sjte diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction�de'
onl l GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
�L �l (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
Fn,-naallow land surface: construction to the following:
Fm�mulrip(v,rcl/c liar all depths indinnerent(example-3(¢'_'f10'and 1�tJ,100')
40 (ft,) Division of Water Resources,Information Processing Unit.
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
In eater•level 4,above casing,mw"�
11'.Borehole diameter. 6 1/8 (in.) 24b.For injection Wells: in(acidition to sending the form to the address in 24a
above,also submit one copy'of this form within 30 days of completion of well
Air Rotary
12.Well construction method: constntc[ion to the following:
(i.e.auger,rotary,cable,direct push.etc.) Division of Water Resources,Underground injection Control Program,
E
PPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one cop}' of this Yonn within 30 days of
Chlor Tabs Amount: 1 1/2 Lbs completion of well constr ucnbu to the county health department of the county
ype: where consnuctcd.
Revised 2-22-'_t116
North Carolina Department of Environmental Quality-Division of Water Reb lurces
Form GW-1