GW1-2022-01857_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague tAr R ;iivt s
FROM TO DESCRIPTION
1Vell Contractor Name FEB 16 202Z aft. 7 z)rt. /p /Y)
B&K Well Drilling Inc n ft
�'.' '*Urdl
NC Well Contractor Certification Number !ft+•'�`s+f�' a t5 0UTE9V'. NG uirifWcased hells f?K'f 1 R iF' °b
2857-A °" � y FROM TO DLIMETER. THICKNESS MATERIAL
p ft• 61/6 in. SDR-21 PVC
Company Name
lb 3ivi+l$IiCAS(iG01t FU$tAl eeermat:ctose�t-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.well Construction Permit#: rt ft, in
Lint all applicable well construction petmtts t.0 U1C',Lbunty, tote.Variance,etcJ
ft. ft. in.
3.Well Use(check well use): -
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public fL ft. in.
Geothermal(Hcating/Cooling Supply) esidcntial Water Supply(single) ft ft m
esidential Water Supply(Shared)Industrial/Commercial pP y( 18 t TtD131
,..
FROM TO NLATERLAL EMPLACEMENT METHOD&.AMOUNT
Irrigation
ft. tt.
Nun-Water Supply Well:
Monitoring [3Recovery
injection Well: ft. rt.
Groundwater Remediation
Aquifer Recharge I 19:5AIVtNGlt9.u1 b#rAGlc flf. "awe
Aquifer Stor9ge and Recovery [3Salinity Barrier FROM R,.:} To NLATERLAL EMPLACEMENT METHOD
gg�Stormwatcr Draina o ft. ft.
Aquifer Test �
Experimental Technology oSubsidence Control ft tt.
f8 s]�etsa€:
Geothermal Loop) Tracer
2o: ItIL1INC:1:00:ittelt:additiorfal
(3 aeeeSs
FROM TO DESCRIPTION rnlor,tiardnqs,solUrcek rein size cue)
Geothermal(Heating/Cooling Return) nother(explain under 921 Remarks) tt Ir
ft.
4,Date Well(s)Completed! Well ID#
G ft. t
0 f CJt U V
Well cation:
n ft. ft.
C ( ft. tt.
catty/Owner Na ie Facility 1D#(i a licable)
physical Address,City,acid Zip
County parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latJlong is sufficient) 22.CertlflC
N W
Silmatun of CenificJ Wcll C acusr', Date
6.Is(are)the well(s)oPermanent or Temporary
eeaaa,,,,,,ttt Av.cigning this form,I herelry certify that the xellls)was(were)coastructed in accordance
7.Is this a repair to an existing well: [3Yes or No ,ith 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards rend that a
1d .plain the nature of the copyof this record has been provided to the well owner.1/•this a a repair,ill out known well ennstrucnon information an te
repair under#21 remarks section or on Me hack of this.for n. 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
construction,only JAW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well dept below land surface: 0� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple wells lest all depths ifdii fereni(erahnple-3g200'and 2 ti 100') construction to the following:
10.Static water level below top of casing:
40 (ft.) Division of'Water Resources,Information Processing Unit,
1f tvater level is above casing,ore"+ 1617 Mail Service Center,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 .For Water Suuoly&Iniection Wells: In addition to sending the form to
24c
132.Yield(gpm) ` ® the address(es) above, also submit 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.
Revised 2-22-2016
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources