GW1-2021-00020_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD (GA-1-1 For)eternal Use Only':
1.Well Contractor Information:
Robert Teague FROM
warERZ O'
FROM TO' DF.SCRTPTIO!V
Well Contractor Name ft. ft.
B & K Well Drilling Inc fr. ft.
NC'well)'ontacior Cenilication Kumber 15.OUTER CA.INK for diutti-eased wells OR LINER-if:e licabkf
FROM TO I DUME7ER THICKNESS M. ERtAL
2857-A p ft. ft• 1 c t/B in. SDR-21 PVC
Company✓ante 16.INNER CASIN 'OR TUBING eV H
rinal closed-loo
(� FROM TO DIAMETER TICKNESS Nt�TER1AL
2.Well Construction Permit I tf: ft. ft. in.
List dl appliwble x'ella crsrn(aiui pc'''+ n/i.e.UIC'.Connn..Sluly Yariarar,ch') .
ft. ft.
3•Well Use(check well use): 17.SCREEN
Water Supply'Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
E)MunieipahPublic ft. fL in.
Agricultural
Geothermal(I featinglCooling Supply) Residential Water Supply(sin lo) ft, it. in.
lndustriallCommercial DResidential Water Supple(Shared) Id.GROUT
FROM TO MATERL•t1. ENIPLACE%SENT%tF,TAOD K AMOLNT
FlAquifer
ft. ft.
upply Well:
�Recot'ev\ ft. ft.
ll: ft. fr.
harge ®Groundwater Ren.ediation 19,SANDIGR4VELPACK if a lfcable)
�Salutily Rarcier FROM TO ?LITERLAL EMPLACEMENT MET HOD
rdge and Rzcoiery
it. ft.
Aquifer Test DStont)watcr Draina_e
Subsidence Control ft' ft.
Experimental Technology t�� :.
:1..(jeothermal(Closed Loop) Tracer 20c DRILLING LOG(attach additional.sheets ifnemssa
FROM TO ESCRIPT N color.her n ss.solUr-ckt1w.2min size,ee)
iGeothermal(lieating/C:oolin Return) n0ther(explain under 21 Remarks) R.
ft.
4.Date Well(s)Completed: � �-1 Well ID-4 i
rl. rt.
S Well Location' ft. ft.
C es S L ! ft. ft.
Facility+owner Nama Facdi ID=iif applicable) _
-1 // f / ft. ft.
Physical Address.City.mid Zip 21.REMARKS
County Parcel ldeutilicauon N0.(PIN) ESS1N�
Sb:Latitude and longitude in degrees/minutes/seconds or decimal degrees: s
22.Cet
(ifwcll field,one IxL'IOnY is soffit lent)
'
\rF'
Date
S11LI1Lt Urc of Certified Well CU. rector
6.Is(are)the well(s)(BPermanent or [3Tempnrary'
Br s;gning this loan.1 battle:a•rtifi-that the x•clllal xns(x•crc)r•nncrnu•tcd in aC('nr(iunCe
�ridi!SA�<-.{C 01C.Ol00 ur;5.9;.C.{C+)K'.0100 fuel!Cuiarurriui Smndards cold ihnt a
7.Is this a repair to an existing well: 0Yes or m rnpr n(Ihis rctnrd has been prm:i ICd to the xt/l mna r.
Ifthit is a repair.fill ma l-u0-1 well['nnspvC(inn inlor,tiaiian PNvlain the nat'ac ofrht
repair under I%:!rrniarks srrtion ur�,n der hark ufihi..iorni. 23.Site diagram or additional well details:
You may use the back of this page to pmtide additional well site details or.`ell
8.For Genprobe/DPT or Closed-Loop Geothermal Wells ha\ing the same construction'Us details. You this also attach additional pages if necessary.
constniction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
S (ft.) 24a. For All Wells: Submit this form within 30 day. of completion of s�'cll
9.,Tota1 well depth below-land surface: constniction to the following'
Far andliple'irlle list all del,dis it di/)'rent,zrnniplr-_i�i`flo'and 24j,4001
40 (ft.) Division of Water',Resources.Information Processing Unit.
10.Static water level below'top of casing:
q'care,loge!it ohm e.asiag.+ '.'"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter•_ 6 1/S (in.) 24b.For lniection Wells: in addition to sending the form to the address in 34a
Air Rotary above, also submit one copy of this form within 30 days of co,i1*60n of well
12."'ell construction method:
constriction to the following:
(i.e.auger,rotary.cable.direct pusli,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 Row 24c.For Water Supply&ilniection Wells: In addition to sending the form to
13a.Yield(gpm) Me the address(es) above, also submit one copy of this torn within 30 days of
Chloe Tabs 1 t/2 Lbs completion of well constru'ctiou to the cortnty health department of the county
13 b.Disinfection type: Amount:
whet consnve[cd.
'-I Nonit Carolina Department of Environmental Quality-Division of Rater Resorirccs '_,.Revised
Form GV.