GW1-2021-00175_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD (GA-1
For internal Use Only:
I.Well Contractor Information:
14 WA-TER:Zt)NES DESCRIPT1Oti
Robert Teague FPONI TO
fit.
Well Contractor Name L. C
B&K Well Drilling Inc ft. fit
NC Well Contractor Certification Number FROM TO IS UFITERCASLfl1G#or insitfc DLAME�R lb'� CIiNEss a MATERIAL
2857-A 0 ft. ft, 6118 in. SDR-21 PVC
16i:1NIVivItC�51P1G 01t f:t1$YNG e[�es'maf:ctosed too '
Company Name > •�/� OtAM ETER THICKNESS MATERIAL
t 7: /
2.Well Construction Permit#: /
FROM R TO.
List all applicable Nell cotrstntction permits(i.e.L/1C'.Comm,State, Variance,eta.1 ft
3.Well Use(check well use): t',:SC71IEEty
Water Supply Welt' FRONI TO DIAMETER m' �WTSIZE THICKNESS MATERIAL
Agri cultural [3MunicipaL'Public
15cot6nnal(Heating/COOling Supply) Residential Water Supply(Singh) ft tt In.
Ind ustrial/Comntercial Residential Water Supply(shared) LB.: ROI3t nt.+TERt�1
.. FROM TO EMPLACEMENT METHOD&AMOUNT
Irrigation ft. tt.
Nun-Water Supply Well: ft. ft.
Monitoring DRecovery
ft- ft.
I
njection Well:
Recharge [3C;roundwaterRemediation ly_SpNVIGgayE1 AC1C:{tlf EMP�acEMEVTMETHo6
r Storgge and Recovery [3Saliniry Barrier
FROM TO M.9TERLAI
ft, ft.
LGeothermal
Test Drainage
ntal Technology
it ft. ft.
pTracer 29IIR[ILIIVG'#OG itttaeltaddttitiiiatiheet3if:iiecess
IClosed Loop) � FROM ESCRIPTION Coto.hard s eoivrock a n»n size,Ctc.)
al(Heatine/Coolin Return)
Other(explain under#21 Remarks) tt `
4.Date Well(s)Completed:1 Well ID#
fit. fit.
r
5a.Well rLocation: ft. ft-
ft. ft.
Facility/Owner Nance Facility lD�(if applicable)
/\t.D c fin 1//
Lb
Physical Address,City,and Zip
'21::RE1ifA1*;KS
��..^ Parcel Identification No.(PN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certificatioil- �---
(if welt field,one lathong is sufficient)
N
W
$igtta urn of CcrtificJ Wt+ll Conte tr
Ditto;
6.Is(are)the well(s)oPermanent or oTemporar}' g1,signht¢this(ono.I herehv certify that the well(s)tvac(were)constntcied in accordance
Yes or No irith 15,4 N'CAC 02C.0100 or 114,NCAC 02C.0200 well Construction Standards and that o
7.is this a repair to an existing well: copy o(this record has hcen provided to the well out,er.
/jthit is a repair,fill ov,brown well canstructiat inJonnO inn an explain the nature of the 23.Site diagram or additional well details:
sepal,under�21 renrurks section or on the hack ujthis loon.
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.
constnuction,only 1 GW-I is needed. indicate TOTAL NUMBER of wells gUB1N11TTAL INSTRUCTIONS
drilled:
9.T.otal well depth below land surface: --(tt) 24a. For A_ 11_Wells: Submit this form within 30 days of completion of well
Fnrmultiple,ells 1w all depths ifdifferent teratnple-34%v'00'and-t`r�,100'?
construction to the following:
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
!1 trailer level Ls ahove casing use"`
6 1/8 (in.) eet____ion Wells: in addition to sending the form to the address f
11-:Borehole diameter 24b.For lni
. above, also submit one COPY of this form within 30 days Of completion of well
12.,Well construction method:
Air Rotary co;rstntction to the following:
(i.e°iauger,rotary,cable,direct pus1L etc.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Method of test: the a
Air Flo_W---.124c•For Water SntrD1Y&Infection Wells: In addition to sending the fain to
13A.Yield(gpm) ddresses) above, also s ubmit one copy of this form within 30 days of
Chloe Tabs 1 V2 Lis completion of well conitractlou to the count}' health department of the count)'
13 Amount:b.Disinfection type:�_---- _..—.--j whcrC CunsttuctCd. i
North Carolina flepartmect of Emirenmental Quality-Divtsiou of Water Rest?ttrcc,
Revised'-_"_--Olo
Form GW-I
i