GW1-2021-00226_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1,Well Contractor Information:
Robert Teague l4.W.ATER:zo�
FROM TO DESCRIPTION
Well Contractor Name % C ft. ft• �yN
B&K Well Drilling Inc r,> ft, L ft. i
NC Well Contractor Certification Number I&Ol3TElL:GAS1#`1G for to '. seed eRs DR U-14 tf tte3
DL NMI TIUCKNESS
FROM 11 TMATERIAL
2857-A D rt. ft. s va in. SOR-21 sire
Company Namc 16::1NNERCA-MOGOR'.TUBINC+' eat closed foo
FRONT TO DIAMETER THICKNESS MATERIAL
2.'*Yell Construction Permit#:'` f\ �C IC a� {t rt• in.
List'all applicable well consrruction permits(i.e.Ul(• Counn+.Stare.Variance,err.) to
ft. ft.
3.Well Use(check well use): t:7,SGREEfif;
Water supply well: FROM TO DIAMETER T.SIZE THICKNESS MATERtAI
Agricultural E.J
p�Municipal/Public ft ft. in.
Gcothennal(Heating Cooling Supply) R fi csidcntial Water Supply(single) ft in
Residential Water Supply(shared) 18:GROUT::: `
lniiustrial/Comntercial NIA ENIPLACEMENTMETHOD&AMO[TNT
FRONT TO
Imaation ft. ft.
Non-Water Supply Well:
Monitoring
ORccovery ft' ft'
injection Well. ft. ft
Aquifer Recharge ®Groundwater Remediation
i10 S;ANI)IGRAvEL.P4CK Qf' )lcablel' .EMPLACEMENTnIETROD
$alini TO M.ATERLAL
Aquifer Storage and Recovery � n'Barrier FRONT ft. ft.
Aquifer Test DStormmatcr Drainage
Subsidence Control it' tc
Experimental Technology -
Geothermal(ClosedLoop) DTracer MOOT IEINCLOGfauachDESConekslNcolfnecess'
FKOM TO DESCRIPTION Colo.bard sabroeA h � urn size,etel
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. 1'. c t
ft. ft. _ `� (i
4.Date Well(s)Completed: ` Vtt iD#
\ L tc. __hI
' (,r > .
52.1Well Location: ft• ft.
Fa i]ityiOwner Nance Facility IDS(if applicable)
rr- r
Ph}sical Address,City,and Zip Z1.tiR EFARxe
County Parcel Identification No.(PiN)
t,
5b.Latitude and longitude in degrees/minutes/Seconds or decimal degrees: t-
22.Certificatiuw)
(if:wtll field,out IaUlong is sufficient] / "• ( y�
N W -
r Daw
Signature of Certified Wc11 Gmtractu
6.as(are)the well(s)OPermanent or DTempnrar
y
Bv fining this form.1 hereln;certify that the r rl//s)was lcvcrc)consrnicted in accordance
,j .rith 15A NC.4C 01C.0100 or 15A.vCAC 02C.0200 well Construction Standards and that rr
7 Is this a repair to an existing well: Dyes or No cops'ofthis record has been provided to the urll o--ter.
1%this is a repair,flu as brown well construction irybrinatian plain the nature of due
repair under 421 remarks section o'on he back of this form` 23.Site 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 mar'also attach additional pages if necessary.
construction,only GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: $UBDIITTAL INSTRUCTIONS
91 Total well dep elow land surface:
3 � _(ft-) 24a. For AIt Wells: Submit this form within 30 days of completion of well
Fnr nin/tiple wells lar all delydts i%di/ferent(:rainple-3Ce'-200'and 2@1041 construction to the following:
40 (fL) Division of Water;Resources.Information Processing Unit.
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
1j'anrer level Ac ahm•.casing,use
6 1/8 24b.For inieetion Wells: In addition to sending the form to the address in 24a
1:1.Borehole diameter: (1°)
above,also submit one copy of this form within 30 days of completion of well
Air Rotary constriction to the following:
12.Well construction method:
(i.e.auger,rotary.cable,direct poly 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. Air Flow 24c.For Water Supply&.Ilniection Wells: In addition to sending the form to
13a.Yield(gpm) he a'idress(esl above, also submit one coop of this ±our. within 30 days of
Chlor Tabs Amount: 1 1/2 tbs completion of:well construction to the county health department of the county
13b.Disinfection tyPe: — vihcrc consDucted.
Revised 2-22.2010
North Carolina Department of Environmcntai Quality-Dn'i:.ion of Eater Resources
Form GR'•1
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