GW1-2021-00230_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague to;�v,► zolv�s>::<>::::;»:;::>:,.:<:::::>:: :.::::::::::;:::<>:::;>::<:::»:::::>:::>:::;;::<::,::.<::<
FROM TO DESCRIPTION
Well Contractor Name
B&K Well DrillingInc
I VOn. L�U rc. 7 S
NC Well Contractor Certification Number
:15OFIF k:tAslia
2857-A FROM TO DIAMETER THICKNESS NUTERIAL
p ft. -�S ft. 61/8 ' m. SDR-21 PVC
CotnpanyNamc - - --: -: - -
16>1iVI+IERCASINGORT.LM`iG
2.WQII Construction Permit tl: FROM TO DIAMETER THICKNESS MATERIAL
list all applicable well construction permits(i.e.UIC'.Country.State.Variance,etc.) ft. f: in.
3.Well Use(check well use): ft. ft. in.
t7:St ?t Eh1
W ter Supply Well:
PP Y FRUttI TO DIAaI ETER � SWTSIZE THICKNESS MATERIAL
Agriculttual ®Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) DRcsidcntial Water Supply(single) f. ft in.
hared ::::._::::.'.....:.:: :.::...:::: .::::::::::::...:::.......::.
IndustnaUComntere,tal Restdenual Water Supply(s )
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E...f ;t&G [Tt7't':>:»>::» : :>::>:::: ::;::>:: >:>;>:: ;'<; :s:<a;<;s::-;»::;>>::;>s:<;»s:z::;;:-r:_<:::sr:;
Irrigation FROM TO NLATERLII, EMPLACEMENT METHOD&_AMOUNT
Nun-Water Supply Well: tt_ fL
Monitoring E)Recovery
injection Well:
uifer
water
Aquifer Stordae and Recovery ElSalinrlud Barrier �laaon FROM TO gLATERl
19.�RiVt?1G8ifYRl:f'?iFK 6f
. q g �, � ry Al+ EMPLACEMENT aIETHOD .
Aquifcr Test [3Stotmwatcr Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop)
Tracer 2&;BRII.ETNG'IOG� 'ttaiiiRddiueri8#s�eeaa'€r '
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color.hardness soil/rocA ;n sae etc t
l ft. S ft.
4.Date Well(s)CompletedA 1 - l L -'Z 1 Well ID# ft• tc*
tt. ft.
5a.Well Location: s
ft.
Via_ ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. —t,
f
ft.
rt.
Physical Address,City,and Zip ) 3 V N S
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C2EN
County Parcel Identification No.(FIN)
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Cernific. on
N W t ► , 6J ��
b.ls(are)the well(s)OPer Sip: ture of Certified Wcll Contractor Datc
manent or [:)Temporary
$v signing this forin.I hereby,certify,that the wellfs)tvas(xere)corsrnrcted in accordance
7.is this a repair to an existing well; 13Yes or No vith 15A NCAC 02C.0100 or 15A.NCAC 02C.0200 Well Construction Standards and that a
1%tht's is a repair,ill our known well construction infannation a explain the nature of the copy of this record has been provided to the xrll owner.
repair under#21 remarks section or on the back of this furm. 23.Site diagram or additional well details:
b.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pagejto provide additional well site details or well
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well dep It below land surface: j (tt) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all deeds 0i ferent(aranple-3r-20O and--'@1001 construction to the:011owing:
to.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
11'rvater level Ls above casing,sae'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1 f 8 (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this fount within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary•cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUP Y WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpr Method of test: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type:
Chlor Tabs Amount: 1 1/2 Lbs completion of well consavction to the county health department of the county
where constructed.
!` Revised 2-22-1_016
Form GW-1 North Carolina Department of Ervironmentai Quality•Dig lion of Rater Resources