GW1-2021-00173_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD(GW-1)
For lntetnal Use Only:
1.Well Contractor Information:
fa wars Rzovl s
Robert Teague MOM TO DESCRIPTION
Well Contractor Name LA S ft. 50 «. 6
B&K Well Drilling Inc ft J- f` G t1..
NC Well Contractor Certification Number FROM TO
mall
4ie11i OR Is" iF
FRONt TO DIAMETER TffiCIi.NESS MATERIAL
2857-A ft. I ft, 6118 to' SOR-21 PVC
company Name 16ANNERChS11`IG:i3ItFG$DIAM �muefo -JOe MATERIAL
FROM TO ETER THICKNESS
2.Well Construction Permit#: l l�� f[. ft• in-
List all applicable well construction permits/i.e.UIC'.County.Stare.Variance,etr.l ft. ft. in.
3.well Use(check well use): t7,.SCREEN
FRONT TO OIAhI ETER ' SLOT'
THICKNESSMATERIAL
Water,Supply Well: ft. in.'
Agn cultural Municipal/Public ft
In
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) rL «
IndustriaUCommercial oResidential Water Supph'(shared) 181.GR0M-
ITER
FROM TO \I. LII. ENtPLACEMEhT\IETRUD&AMU[iNIT
Irrigation ft. f[.
Nan-Water Supply Well: ft. ft.
Monitoring DRecoet:ry
Injection Well:
Aquifer Recharge Groundwater Remediation 19tSAND/GIL4-EL PACK41f Ilcahle)
FROM TO DIATERLAL EMPLACEMEVT
Aquifer Stordge and Recovery [OSaliniry Barrier
MET HOD
ft. ft.
BAquifCTTcst [3Stonrlwater Drainage
Expelimental Technology Subsidence Control
Tracer 19;DRILIANC LOG ALtfltlr Hd hOi19 SI!¢Et5:1f i1CCe3�9
Geothermal(Closed Loop) FROM TO DESCRIPTION color.ha no«soil+rocl rum size,Mcl
Geothermal(Heatin Coolin Retum) Other(explain under#21 Remarks) It. { (j
• ft• 1 I � (, � _ _
4.Date Well(s)Completed: 1:3' 1— Well ID# I ft. ff``'' r
5a.Well Location: ',ft. ft. '�ox f -1,
ft. ft.
Facilityiowner Name Facility ID=i if applicable)
ft. tc 1 r tr r• '�
sr
I ft. fr
physical Address.City,and Zip
IF RE1k1ARKS
C
- Parcel Idtntifiwuon No.(PIN)
County _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Cel tificatio
(if well field,one Whore is sufficient) _ -
N
W ► �- �
1 si ntalun:of C xtiticJ We mtracuu
Date
6.1s(are)the well(s)OPermanent or [3Temporar}
By signing this(ono.7 hrrclry trrtiLj.that the xrll/.tl tuns l><'crel cnttunrcred r nand to t o
Yes nr with 15A.vC.aC 02C.0100 or l iA NCAC 02C.0200 well cunstracaun Standards and that a
7.Is this a repair to an existing well: Na cop)'of this recnrd ha.s been provided to he v.-ell oirnrr.
1f this is a repair,l<ll our blown well consimc ion in/onnatinn .rplain the nature of rhr
repair Under#21 ranurr6 sectiun a•on the hark ujthis 1unn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
6.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
constnlction,only)%W-I is needed. Indicate TOTAL N UMBER of wells SUBMITTAL INSTRUCTIONS drilled:
9.Total well depth below land surface: —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
pnr multiple wr!(c list all depdes it di(jerrni(:rmnple-3(iv100'and-'tw/00') constriction to the following:
40 (ft) Division of Water Resources.Information Processing Unit,
10.&atic water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
l('rrater level is al+m•e casing,use
11.Borehole diameter: 6 1I8 (in.) 24b.For infection Wells: in addition to sanding the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.'Well construction method:
Air Rotary construction to the following:
(i.ei auger,rotary,cable.direct push.eta.) Division of Water Resources,Underground injection Control Program,
1636'Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SiJPPLY WELLS ONLY:
di Air Flow 2•tc.For Water SuD Rc D1V Iniection_Wells: lit addition to sending the fortrL to
13a.Yield(gpm) Method of test: the address(es) above, also suomrt one copy of this form within 30 days of
Chlor Tabs Amount 1 112 Lbs completion of Weil construction to the count}' health department of the county
13b.Disinfection type: — where consttuctcd.
iRevised=22-201 b
North Carolina Department of Environmental Quality-Divisior,of
Fortin OW-1 Water Rzsources