GW1-2021-00231_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD(GW-1) I For Internal Use Only:
1.Well Contractor Information:
Robert Teague
FRONT TO DE.SCRtPTiON
Nell Contractor Name
B & K Well Drilling Inc
7 0 7 S LS
NC Well Contractor Certification Number
YE:011'1?EttC:�73itG Ii7ettiie4gl��iv0 .''bR'1R t .�:>
2857-A FRONT ZO DIAMETER TrnCKNESs NULTERIAL
0 ft. ft. 6118 m. SDR.21 PVC
Company Name I .IRr1SikGUR: ttiEsma#E'
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
i.ise all applicable well construction permits(i.e.UIC.Comm,State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
PPY FROM TO I DIANIL-rER SLOTSIZE I THICKNESS MATERIAL
gricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 131ktsidential Water Supply(single) ft. to in.
Industn'a ommerc1alSupply Ras ideatial Water
(shared)
hared
)
Irrigation FRONT TO NLAtTERLAL E VeLACEMENT METHOD&ANfO[tNT
Nun-Water Supply Well: it. ft.
Monitoring EIRecov'ery it. ft.
injection Well:
..'Aq uifer Recharge [3Groundwater Remediation
Aquifer Storfige and Recovery []Salinity Barrier FRONT TO MATERIAL EMPLACEMENT METHOD
Lquest [3Storrtwatcr Drainagental Technology Subsidence Controlal(Closed Loop) Tracer 28:�RII IlhTtsl OG:attackFRONT TO DESCRIPTION lor.hardness,sotUroc6 a rain size,cteal(Heatin Coolin Return) Other(es lain under#21 Remarks) k. ft.
C7 tri
4.Date Well(s)Completed 1 � � Well ID# el Z ft. ft.
ft.
Sa.Well Location:
U U Sf` ft.
rn��c�" � 1 Y11'l S 'r,N � �
Facility/Owner Nante Facility IDk(if applicable) ft. ft. �._�')r„f 1,��A i
y ft. ft. i
Physical Address,City,and Zip Ck I e.,t C3 -
::ZiiRE31 ?<-> 'i=°i<:<::;' 3<-<s;i'':,:.
County Parcel identification No.(PiN)
E;.:",;n,.w tl l•-...1 1(Ui.t.+ ar+rev +
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certifi u�/
N 7 -� I �- ) 2 "c) 1
Sioatutt;ofCcrtified Wcll o 'sera Datc
6.Is(are)the well(s)�x Permanent or []Temporary
Br signing this form.1 herel,v certify that the%r/l(s)ivas(x•cre)constructed in accordance
7.Is this a repair to an existing well: Yes orNnde.
o with ISA NCAC 02C.0100 or hA NCAC 02C.0200 We11 Construction Standards and that a
J this is a repair•ill out,brown well construction information plain the nature of the co/ry'of this record has Fecn provided to the x:ell owner.
repair under#21 renutrla section or on the hack of this form. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constntction,only 1('W-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: �� - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple err/ls list all delnhs ifdiiferent(cramp/e-3C'200'and 2@100J construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
1l•warer level it above easing,tote +'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For infection Wells: in addition to sending the fort to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary.cable•direct pusb,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructW.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016