GW1-2022-01838_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague ts� � y tarrRl>s
FROM TO DESCRIPTION
Well Contractor Name I or. J` Oft.
B&K Well Drilling Inc
NC Well Contractor Certification Number %g fill t5 E ElYGi1$tNG » s9e 'E3& A ``
2857-A 111QOrwp in Pri•C� FROM To DIAMETER THICKNESS MATERIAL
r i1.tG 0j 0 n ft. ft- 6118 SDR-21 PVC
Company Name :
//►► �^ ..X.G:13�NSRG:tSIf!EG.�R.?FtBti�[6' ::. --:d'::. •.. . ...::_..;:
® 7 v FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: / /l rt fL In.
List all applicable Hell construction permits 6-a L11C Cownv,S e.Variance,eted
in.
3.Well Use(check well use):
_............_.......
Water Supply Well: FROM TO DIAMETER SWTSIZE THICKNESS MATERIAL
Agricultural ®Muaicipal/Public ft.
f fLGcothcrmal(Ticatin/C001in Supply) csrdcntial Water SuPPIY(smolt)
—DR
estda ual Water SuPP1Y(s
hared)IndustriaUColmerclal
FROM TO DL",TERU1. EMPLACEMENT 1%1=013&AMOUNr
Irrigation
R. ft.
Non-Water Supply Well:
MonitoringRecovery ft. ft.
injection Well: ft. ft.
Groundwater Remediation
B
Aquifer Recharge � e:i19iSAiVDIsitJ�',�t>�AF�tf� ::;:. .:.:a.:•::;:-:::::::-:..:::.::::;::.
Aquifer Stordge and Recovery Salinity Barrier FROM To DLATERLAL EMPLACEMENT METHOD
Aquifer Test E)Stormwatcr Drainage ft. ft.
Experimental Technology []Subsidence Control
..........
.:..:.,..........
Geothermal(Closed Loop) OTracer ilAl2:1:Ot`"tfaefr
FROM TO DESCRIPTION rnbr. n solVroek in size etc)
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) n• -5 rc.
4.Date VVell(s).Completed: ��1'e11ID# ft. 43ft. 1
ft. iC ft. L
�Facdiity/Owtner
.Well Location: v
rL ft.
r Facility LD#(ifa liable) ft. ft.
Nanx y�tY P t
1 ft. fL
Physical Address,City.aad Zip
->irclessttxc;>; - -
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one far/long is sufficient) 22.Certific do
N W
6.1s(are)the well(s)oFermanent or OTemporary Signature of Certified Well Co actor Date
13v signing this fonn,1 hereby certify that the well(s)was lwere)constructed in accordance
7.!s this a repair to an existing well Yes 0r No pith 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Cunstruction Siandards and that a
if this is a repair,ill out knoxm well construction information n^ copy o(this retard has been provided to the well ouvter.
rplain the nature ofthe
repair under#21 rentar s section or on the back of this fonn. 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
constrtiction,onl} GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well de th below land surface: o'S YL) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple n@llc ILsr all delrths ffeli ferent(aranple-3@200 and 2@1001 construction to the following:
10.Static water level below top of easing:40 (N Division of Water Resources,Information Processing Unit,
If water levy/is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For inieetion Wells: In addition to sending the form 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) S Method of test: Air Flow 24c.For Water Supply&Injection 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 constructed. {i
Form GW.1 North Carolina Department of Environmental Quality-Division of Water Reset=es Revised 2-22-2016