GW1-2022-01849_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD (GA-A) For internal Use Only:
1.Well Contractor information:
Robert Teague FROM TO DESCRIPTION
y 7CN
Well Contractor Name I-t I ft.
L ft.ft. ft.
B&K Well Drilling Inc
Mi:
NC Well Contractor Certification Number • 11A.:0—I.. RCASIMG ff,
FROM 0 .. DIAMETER THICKNESS PVC
2857-A 0 ft. ft- 6118 .n- SDR-
zt 460
j6_:INNkR' V4.G tit I MATERIALCompany Name TO DIAMETE THICKNESS
2.Well Construction Permit#: FROM it. ft. in.
7
List all applicable"-"col'struc"on permits(l.a.U/C.('ounrv.-,late. analice,air.) ft. ft.
.7
3.Well Use(Cheek well use):
Well: FROM T DIAMETERI It�THICKNESS MATERIAL
Water Supply
E3Municipal,`Public ft. ft. I
2Agricultural ating/COOling Supply) residential Water Supply(SinEtIC) ft ft.Gcothciinal(14Cesidential Water Supply kshared) ::.L&GRGUT,': ............
Eb1PLACEMENIIMI:1.1ridustrialiCommercial FROM TO MATE
irri ation ft. ft.
Non-Water Supply Well: tL ft.
o I"t r3Recovery
Monitoring, ft. ft.
Monitoring
Nun-Water
Well: ..........
pAquifer Recharge [3(-jroundWaIeT Remediation 19;*8 WGRAVELPACKAft hCaltilel*
Salinity FROM TO Nt.4,TERLAL E
Aquifer Slor2ge and Recovery ft. ft.
AquifCTTest oSton-nwatcr Drainage ft. ft.
Subsidence Control .... ...
Experimental Technology SIM ttc.)
Geothermal(Closed Loop) Tracer zg;DRfLnNG-Ibbi.G:
FKONI TO
Geothermal.Heating/Cooling Retum) (3C)ther(explain under 021 Remarks) ft. ft.
I ft. 0 ft. /_t "7 &
4,Date Well(s)Completed: Well ID#
0 ft. u ft.
5a.Well Location: ft.
ft.
F, ili[yiDg(iflipplicable)
Fac!liltyi(Own r�Nai;� �
ft, ft.
Ph -al Address.City.and Zip
Parcel Identification No.(PIN)
County
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Ce-' catio
(if well field,one lat/long is sufficient)
• W"'lidlurc of Ccnirl,.d w.It tractor Datc
6.Ware)the well(O OPermanent or [3Temporary this(oral. I hereby cet­66-that the ,,ell(S)iva�(x-crc)comirlicicd in accoidance
Bv.,igning I . n
well; or qNoln 11�ith l5A,,vCAC 02C.0100or IM kAC 02C.0200 wall Construction Standards and that o
E3Yes copy of this recn)d has peen provided in the Moll 0-mr.
7.Is this a repair to an existing '�p in the.nature of the
I jf*thi,is arepau Jqll nu[A7,o%,n well construction ityimnation well details.
urnt. 23.Site diagram or additional
i epair undvi-#21 remarks section or on the hack qf thisfi additional well site details or�,ell
You may use the back of this page to provide
Geothermal Wells having the also attach additional pages if necessary.
S.For Geoprobe/DPT or Closed-Loop G e, constniction details. You ma),
.constniction,only I GW_I is needed. Indicate TOTAL NUMBER of wells !jUg JITTAL INSTRUCTIONS
RUCT IONS
drilled:_ _
) 24a. For A Wells: Submit this form within 30 days of completion Of well
(ft. E ..
.9.Total well deptebielowland surface:'e: -'0 Da 0(r) constniction to the followin.g.
.f lif-ento'T — i Fn,multiple Wlt,h5f all depths i'& 43a�"'
40 (ft.) Division of Water Resources.information Processing Unit,
lo.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
lr%vater level a all—ec-i'te,to'e
the form to the address in 24a
11.Borehole diameter, 6 1/8 (in.) 24b.For TniectiOn Wells: In addition to sending 30 days of completion Of well
above.also submit one copy of this form within
12.Well construction method: Air Rotary construction to the followin t g.
(i.e.auger,rotary,cable,dirc•:t Push.etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail S&'ice Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: I
i lqiection Wells: In addition to sending the form to
[13a.Yield(gp-) Method of test: Air Flow 24c.For Water Su oply.&' .hin 30 days of
Je address(es) above, also submit one cop), or this tonn within
tion to the colinty health department of the county
Chlor Tabs 1 1/2 Lbs completion of well construction
Aniount.
13b.Disinfection type'- whctc consoucted.
Revised 2-22-2016
North Carolina Department of EnNironrieiaai Qual'!Y-Division of Water Resources
Form GW-I