GW1-2022-01859_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW-1 For Internal Use Only:
1.
ell Contractor information.
7 C rg k4�(?i i1 Z101!IES> DES.77
CRTP17ON
Robert Teague FROM
TO
�y 1 �•4
Well Contractor Name 1
B&K Well Drilling Inc FEB 16 2022 waft. 1-IS nt+7ERw�z5-
NC Well Contractor Certification Number „�-- ,.,.f I� Uretl FRODf TO DrAh1ETER' 'THICKNESS
2857-A `, .. 0 ft. ft- 61/8 in SDR 21 PVC
Company Name "1-&1f.NERG I rkSING t�R fi)IRC1G
FROn TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. In.
List all applicable%ell construction permilt O.c.lI1C.eou11N.State.Variance,etc.) ft. ft. in.
N.
3.Well Use(check well use). f3: :;;;::,>; :>:,:<;:;::. s::z::>;;::>: <>::<:>:;;;:<::>:>::::<:;<:;>: A
FROM TO MANI ETER SWTSIZE THICKNESS MATERIAL
Water Supply Well: ft ft. In.
Agricultural �Mlmicipal/Public
satin Cowling Supply) Residential Water Supply(single) ft.
ft. in.
al
thciut (II g/
Goo ::;.:::::::::::::::.::»;•z, is is
• hared ::::::::::.�::.::::.::::.:.....
IndustriaUCotnmercial esidenual Water Supply(s ) saw: nL�TIIti+T> Et�IACTMENintE1HOD&+MouNt
FROM To
lrri atiun ft. %
Nun-Water Supply Well: ft. ft.
Monitoring []Recovery
ft. ft.
injection Well: ,:;;•>;:<.>::..; "'<°`
Groundwater Rrmedianon .............:.::::::: ,:-;;:::::,::::::,:.:::,
<19i:'S'Ri�[#)If§V >PACK$f
......................
............
Aquifer Recharge pL4TERL4L _ EMPLACEhIEVT METHOD
Pp3�Salinity Barrier FROM To
Aquifer Stor2ge and Recovery E..7 it, ft.
Aquifer Test [3Stormwatcr Drainage
fr. ft.
Subsidence Control -:::
Expenmental Technology _ >i. .FiOG: 'ttnth:a elie#sT s. In size,ctcl
Geothermal(Closed Loop)
Tracer FROM TO DESCRIPTION color.MnIn s.toNroe
Geothermal(Heatin Coolin Return) nothe,(es lain under#21 Remarks) ft-
ft.
S rck-
ft. S it' Y
4.Date Well(s)Completed:' r Well ID#
Sa.Well cahon: ft. tt.
rnG I resa ft. ft.
r Facility/owner Name Facility lDk(if applicabie)
ft. ft.
7 /- e ft. ft.
IX
physical Address,City.and Zip
1 _
Parcel idenlific.1tion No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lai/long is sufficient) 19-
W
N Date
tun:ofCt.•rtificJWcll aactoi
c,�a-s txrre)tronnntcted in accordance
6.Ware)the wen(s)Opermanent or Temporary �ta
Bt.signing this Joan,1 Well
certify,that the xrilLc)
ith 1 SA NCAC 02C.0l00 or 1 iA NCAC 02C.0200 Well Consiructian Standards and tlmr u
7.Is this a repair to an existing well:A,.,I,n
es arNo
coy.of this record has been provided to the will ou°ner-
ljrhis is a repair,fill our known xrll conatrurmation and crplain the nature o(the
23.Site diagram or additional well details:
reyuir under#ll renutrls section or on the hack ajthis farm. You may use the back to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
k Of this Page
details. You may also attach additional pages if necessary.
construction,onlyIGW-I is needed. Indicate TOTAL NUMBER of wells SUBMI rALiNSTRUCT1IONS
drilled:
9.Total well de below land surface• b (ft-) 24a.For All Wells: Submit;this form within 30 days of completion of will
For multiple Welk lire all depths ifdlfferent(eranpfe-3ra;300 and?OIOf1')
construction to the following:
40 (ft) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
Ijwafer level it above casing,use"+
6118 (in.) albo For inieet�ell op of thii f to wit iin the a of completion sof well
in 24a
I I.Borehole diameter: above,also submit one copy of this form within 30 days
12.Well construction method:
Air Rotary construction to the following: '
(i.e.auger,rotary,cable,direct push,eIu) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Method of rest Air Flow 24a For Water Sunoly&Infection Wells: th addition to svendthin 0 days of
13a.Yield(gpm} _ the addresses) above, also submit one copy of this form y
Chloe Tabs Amount
• t/2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type:�--- where constructed.
North Carolina Department of Environmental Quality-Division of Water Re iources
Reoised 2-2-1-3016
Form GW-I
I