GW1-2021-00228_Well Construction - GW1_20211213

WELL CONSTRUCTION REC For'Internal Us e Only:
1.Well Contractor information: _ :
Tv.A-M-ii ZQN9
Robert Teague TO DESCRTPI.ION
Well Contractor Name ft. 13 i� tt, C"
B &K Well Drilling Inc ft ft.
si iR4l �OlkUM611t
NC Well Contractor Certification Number I OUTER.CASIIN(i 40r.:61Jatti4a
DIAM TEE THIC &A
KNESS KATEML
FROM TO
ft. ft. PVC
A 61/8 i SDR-21
2857 0 1
�ORT- 10.G:
'INNER:CASIN
Company Narric THICKNESS I IRIAL
FROM TO DIAMETER T
2.Well.I Construction Permit ft. ft. in.
List all applicable well colLsrructiOn Per""15 OX.L%IC.cotoln+.Stale.Variance,etc) it.
3.Well Use(check well use):
Water Supply Well: FROM TO
Agricultural
o MunicipaUPub lic
cothennal(Heating/Cooling Supply') []Residential Water
Supply(single)
fL in.
ladustialConm ercial EResidential Water Supply(shared) FROM
EMPLACEMENT
ENT
Irrioation
ft.
Non-Water Supply We ft.
Monitoring DRecovery
Injection Weu. ft*
E)Ciroundwater Remediation 19,SANJN.GRXVELF%,CKrtfi' licable)
:)Aquifer Recharge [3Saliniry Barrier FROM TO i%IA E EN IPLACEMENTMETHOD
7AqiIifer Storage and Recovery [3Stormwaccr Drainagc ft.
Aquifer Test ft.
Experimental Technology [)Subsidence Control
24.DRILLINGL*GG:suachi"fion
Geothermal(Closed Loop) [)Tracer FROM TO VSLRIPTI'�ii�'! colon d.slx s fl/rock _i.size,etc)
under#21 Remarks) ft. ft.
nGeothermal(Heatting/Cooling Retum) nOther(ex lain
ft.
4,Date Well(s)CompletedA Well ID# ft.
Sa.Well Location: • ft.
ft.
Facility/Owner Nante Facility iDg(if applicable) ft. ft.
ft. ft. 202-1-
Physical Address.City.and Zip C
k')r
Parcel Identific4ition No.(PIN) —
County
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certift
(if well field,one lat/long is sufficient)
N W
a
D�lc
donce
Permanent or [DTemparary piaturc of Certified wol Contr,icV r
6.li(a re)the well(s)o By vignine this form,I herciry certify hot the­11(.0 lv&%(wc)co
crnsinicted in act
lh l5AA'C-4C 02C 010 or IjANCAC 02C.0200 well Cunsrmcrion Standards and ha­
7.Is this a repair to an existing well: E)yes or No copy of thiS record has I,cc?j prnvidcd to the well o,,-ncr.
ffchi%is a repair,fill our known well construclio),inforinazion andNvlain the nature of the
el"i-ir under021 rentarkssection or on the back qf this form. 23.Site diagram or additional well details: or well
11 the same You may use the back of this page to provide additional well site details
8.Fbr Geoprobe/DPT or Closed-Loop Geotbermal Wells haviiig construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
lli d- <�7 -SuBrIlITTAI INSTRUCTIONS
drilled:
cc: —(ft-) 242. For AR-ML21hi: Submit!this form within'30 days of completion of well
9.Total well depth below land sur
construction to the follovvin­
1w all depths ifdrfferenl(arm
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
If vare,.level is alrive casing,use
ii.Borehole diameter: 6 1/8 24b.For Inie Wells: In addition to sending the form to the address in 24a
above,also ctionsubmit one copy or this form within 30 days of completion of well
12.'1 Well construction method: Air Rotary construction to the following: i
jl.e:'.auger.rotary,cable,direct pusli.etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FojR WATER SUPPLY WELLS ONLY: : ction NN-ells: In addition to sending the form to
Method of test: Air Flow — 14c.For Water Supply Ajgts��� v of this form within 3 0 days of
I •Yield(gpm) 7 b — the address(es) above, also submit one cop. department of the county
Chloe Tabs Amount. 1 1/2 Lbs completion of well construction to the county health de
13b.Disinfection type: wrici-cuonstiucted.
Revised 2-22-20 16
North Carolina Department of Environmental Quality'-Divi,,;;on of Water Rewu"c'
Form GW-I