GW1-2022-01856_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only:
1.Well Contractor Information:
Robert Teague
14.WATER ZpNES
..: ��'" FROM TO DESCRIPTTON
Wei I Contractor Name '`_��� x �� Cft. 5ft• �t�,
B&K Well Drilling Inc rt rt.
FEB 16 2022
NC Well Contractor Certification Number 15 Oti1EIt GA,KG*' "iituth rased syelts bYT1 l Zl iT »�
2857-A n^* ^•tn4 r11' FROM TO DIAMETER THICKNESS MATERIAL
i "�ltv;i«` it t..�..;�,..,.J �� _
0 ft-
t ft-
CompanyB 1/8 in* SDR-21 PVC
Name
lti:>1N1Y1 KGA$1#Gf3ft F_tfBDIAM eefAeFinat:t(ICKNES
FROM 'TO DIAMETER THICKNESS �� MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List rill applicable well construction permits(i.e.UIC',County,State.Variance,eteJ
ft. ft. in.
3.Weil Use(check well use): -
Water Supply Well: FROM TO DIAaI ETER %LOT SIZE THICKNESS MATERIAL
Agricultural ,3Municipal/Public ft ft. in.
Geothermal(Hcating/Cooling Supply) JResidential Water Supply(single) ft. tt m
Industrial/Commercial esidential Water Supply(shared)
FROM TO DL�TERLAI. ENIPLACEMENT METHOD&AMOUNT
Irrigation ft. ft.
Nun-Water Supply Well:
Monitoring Recovery
injection Well: ft. tt•
Aquifer Recharge r3Groundwater Remediation
19`�AiVfNGi��EL#'ACIf'Gf b!e <, , ;
Aquifer Storilge and Recovery [3Saliniry Barrier FRONT TO ALATERL4L EMPLACEME.NT METHOD
Aquifer Test [3Stormwatcr Drainage ft ft.
Experimental Technology C)Subsidence Control ft ft
Tracer 2RIi73FINGi1UG.att8cb:8ddihonal;illeet9 .._.
Geothermal(Closed Loop) FROM TO DESCRIPTION colonhard s eolUrocAb tasizc,ctcl
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) ft- 7s R. ' 0 '
4.Date Well(s)Completed: -0 11! Well ID# ft O ft. L
t. ft.
5a.Well Locat• n:
ft. ft.
ft. ft.
Facility/Owner Name Facility LD#(if applicable)
ft.
Physical Address,City,and Zip -
L
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) :qpurlurc
.Certi
N W
of Certified Well ontractor� Date
6.ls(are)the well(s)OPermanent or 13Temperary
By signing this torn,1 hereby certify that the well(s)was(were)constrttcrcd in accordance
7.IS this a repair to an existing well: [3Yes O.-KN. with 1.5A NCAC 02C.0100 ur 15A NCAC 02C.0200 Well Construction Standards and that n
if this is a repair,ill out known well construction informadotxplain the nature of the cop}'of This record has been provided to the well owner.
repair under 921 remarks section or on the back of ihis.furm. 23.Site diagram or additional well details'
You may use the back of this page to provide additional well site details or well
S.For Geo oly I G or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
coconstruction,,onlyW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� 00 24a. For All Wells: Submit rhis form within 30 days of completion of well
For multiple wells Zia all depths if different(Trample-3@M0'and 2@1001 construction to the following:
10.Static water level below top of casing:
40 (ft.) Division of Water Resources,Information Processing Unit,
1f water level Ls above casing,use-+' 1617 Mail Selvice;iCenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Iniection 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 push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
\ � Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also subunit one copy of this form within 30 days of
Chlor Tabs Amount- 1 1/2 Lbs completion of well construction`to the county health department of the county
13b.Disinfection type: where constructed.
Form GV.'-1
North Carolina Department of Environmental Quality-Division of Water Resouric es' Revised 2-22-2016
i