GW1-2021-00177_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD(GW-11
For lntemal Use Only:
1,Well Contractor Information:
R7.isvEs
Robert Teague FROM TO DESCRIPTION
4Ve11 Contactor Name
� ft. 2 ft. SO
B&K Well Drilling Inc rt.Ic:vFIiE>1traslsuG rL;; ''
speth. # MATERIAL
NC Well Contractor Certification Number `FROMTO niAMETER. THICR74ESS
2857-A o ft. ( ft. 61/8 • SDR-21 PVC
Ib liv�iTER16 EflR N� tliatm:d
Company Nardi: ` , TO DIAMETER THICKNESS MATERIAL
S � FROM
2.Well Construction Permit#: fL ft
in
List all applicable well construction permus a WC.Comm,Stare, ar atce,etc.) ft. R. in.
3.Well Use(ch
eck
ck well use):
f75i�" WTSIZETHICKNESS.....MA TER
FROM TU DIAMETER
Water Supply Well: ft tt. in.
Agricultural [3Municipal/Public
anal satin Cooling Supply) Rtaidential Water Supply(Single) rL ft.
In.
the €/
sh are d
)u v of Water ' 'i;i;? Ci::?:2cF> ii`i &-
IndustriaUCommeruialResidential W PP- ( t8r:fvlii DL1'I•ERL1I. EMPLACEMENT ArE'r13UD
FROM TO
lrriaation ft. ft.
Non-Water Supply Well: it. ft.
Monitoring Recovery
ft. ft.injection Well:
Groundwater Remediation Aquifer Recharge �'SaYN#1/G1�>7?1.PACff Gf EMPLACEMENT DIETHOD
FROIsI SO ERLAL
Aquifer Stor2ge and Recovery �Saliiliry Barrier NLAT
ft
tt
Aquifer Tcst [3Storinwaccr Drainage
Experimental Technology Subsidence Control
ft ft.
Tracer 2&Bitii E]NG:IUG•atttiidt:sdd+tiotta3sleis:�-
Geothermal(Closed Loop) � FROM To DESCRIPTION eol .hardness,soiurocl n in stzc,etc)
Geothetmal(Hearin Coolin Return)-
Other(ex lain under#21 Remarks)
1_, well ID# 2 S 6f`• }^a !v�-
4.Date Wells)Completed: ft. S d ft. jn(j Y —� N/
5a.Well Location: 1 ft. ft.
ZY5 ft. ft.
Facility/Owner anx Facilityt�D)O(if applicable) ft. ft. ?021
......................
Physical Address, ity,and Zip I $;<:,
Parcel identification No.(PiN)
County
56.Latitude and bngitude in degrees/minutes/seconds or decimal degrees: 22 Certificaatt'G/CT `
(if well field,one lat/long is sufficient) f a 1
N W (/ tD ,;
SiEmaturc of CcttificJ Wcll Cunwsurr',
6.1s(are)the well(s) Permanent or Temporary
By signirte this(ono,]herefry certify,that the ne/lGr)was(x•ercl co2micred in accordance
with 15A NCAC 02C.0100 ur 1 iA NCAC 02C.0200 well Construction Stundurds and that a
co •of this record has been prnvided to the cell oicner.
7.Is this a repair to an existing
well: Yes nr No copy
ffthis is a repair,fill otu known well construction lnfortnatiot a rrplain the native of the 23.Site diagram or additional well details'
repair under tl21 r marks section or on the hunk ujrhis.(unn.
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth belo 'land surface: O (ft) 24a. For All Wells: Submit this form within 30 days of completio» of well
Fm.multiple,veils list all depths 1fd{fferent(eranple-3r'_'00'and_'@I00�
construction to the following:
Division
40 (ft.) of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If water•level is abom casing,ace"+
6 1/8 (in.) 24b.For inieetion Wells: in addition to sending the form to the address in 24a
11-Borehole diameter: above,also submit one copy of this form within 30 days of completion of well
12.W construction method:
Air Rotary construction to the following:
(i.e.augerger,,rosary,cable,direct push,etc.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
v Method of test oDy Injection V1`ells: In addition to sending
Air Flow 24c.For Water Su l & the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
Ghlor Tabs Amount:
112 Lbs completion of well construction to the county health depatmteat of the county
13b.Disinfection type: where constructed.
i Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Reso`rces
Form C W-1