GW1-2022-01864_Well Construction - GW1_20220216

1 For Internal Use Only:
WELL CONSTRUCTION REC GW_
ORDS-1
..............
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1,Well Contractor Information:
' •:3�.�k' }IIC'S..::::.... DESCRIPTION
FROM TO
Robert Teague
Well Contractor Name �� ft ft.
B&K Well Drilling Inc r t8 1 ZnZ— �ts<" :s + S n,LaTE,tint
35ONI TO DIAMETER'
NC Well Contractor Certification Number i in- SDR 21 PVC
(rttr{ '1'�raC r �{:t�tlrlil FRonl It. 61/s
ft
2857-A ::. MATERIAL
IG:1NR THICKNESS
FROM TO DIAMETER
in.
Company Name (t.
ft.
2,Well Construction Permit#: ft in.
permits(i.a L lC.Gomr,. fate.Variance,etc.l ft.
"Zio
n
r
'able ue!i cotutry
List all applicable .........:.�::::::::::::<.:.::;'t: :::�:::::::i:;fi{>;5:yi::'rt; ::`::::;<�::::ii>:�:::::i:;s:.;.
y;t?SEA TSIZE THICKNESS
MATERIAL
3.Well Use(check well use): £i9a::::r DIANIETex >'w." •:;::::......
FROM To In.
1 Well: ft. ft.
Water SnPP Y �lviunicipaVPublic
) ft. in.
Agricultural 'al Water Supply(single ft ::::::.;.;•;..:..;.;;;.:;:.::.;
Rcatdcn❑
- O
tMotnsT
Gcotheynnal(HCating/CoolingSupply) l shared) »>:>;>;; »s:z::::<;>.:s>::•::
�Residenual Water Supply( : TO?
ALATFRLt1. EMPLACEMENT ME'ra
Industrial/COmmercial FRo�i
ft. ft-
irri ation it.
1 (t.
Nun-Water Supply Well: ORaovery
ft.
Monitoring f t n19TE .
injection Weil: Groundwater Remediation Ty;. G1ZYET 1� �� EMPLaCEntE`[T niETHOD
Aquifer Recharge FROM To
OSalittity Barrier ft ft.
Aquifer Storage and Recovery [3Stormwratcr Drainage
ft.Aquifer Tcst
OSubsidence COII1I01
iaddt�it ,n slze,ctd
Experimental Technology aownici.
^�^ DECCKIPTION ¢abr.hard
Tracer FRODI TO
Geothermal(Closed Loop) ft.(.
geatirt Conlin Return) . Other(er lain under#21 Remarks)
Geothermal( ft, tt• �-r
4.Date Well(s)Comp
leted:2� 1 1 Iell ID# ft. ft.
ft. ft.
Sa.Well Locat n: V , u
tt. ft.
V`-C, Facility ID#(if ap iI ble) ft. ft.
F eility/Owner Name
ft.
C
z:
Physical Address,City.and Zip
Parcel identification No.(-PIN)
County
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certifi n'
(if well field,one latilong is sufficient) W d
N Date
,lp[atune of Cori a ell n a'
g,signing this form.1 here, certify[hat the xell/.Q was Ix ere)consrn[cted in accordance
s)aPermanent or OTemporary
with 1 SA NCAe 02C.0100 or iiA N-01 02C.0200 Well Construction StunJorJs nnJ that n
6.Ware)the well(
7.Is this a repair to an existing well: Oyes Or ON. copy of this record has been provided to the well o,ener.
if this is a repair,ell out b[omi well cnnstructiou information and explain the nature of the 23.Site diagram or addition well details:
You may use the back Of this page to provide additional well site details or well
k,jthis f
,•,pair under#21 ren[arla section or on the baraun.
robe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary•
S.For Geop
construction,only 1 GW l is needed. indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS construction, of well
drilled: (fL) 24a.For A�S: Submit this form within 30 daysof comp
9.Total well dep below land surface:
Far nmftiple wells l[v all delnks ifdiffe+enI(ara nple-3r-'00•and 1 a@100� COIIS[i11Ct10II t0 the f011oW1IIS:
40 (ft) Division of Water Resources,Information Processing Unit
f casing: 1617 Mail Service Center,Raleigh,NC 27699
10.Static water level below top o -1617
if water level is al+ove casing,,uuse�'O of completion of well
1 O (in) 24b.For ini�we[is°��in addition to srnding the form to the address in?4a
11.Borehole diameter: above,also submit one copy of this form within 30 days
12.Wen construction method:
Air Rotary construction to the f0llOwin9:
(i.e.auger,rotary,cable,direct Push etc.) Division of Water Resources,Underground injection Control Program,
ice Center,Raleigh,NC 27699-1636
1636 Ma Sery
FOR WATER SiJPPLY WELLS ONLY: to
Air Flow 2dc For above, also Isubiniinoneeoopy of this form swithin 0 days of
Method of rest: the addresses) health department of the county
13a.Yield(gpnt3
Chloe Tabs 1 1/2 Lbs completion of well wn:tiuction to the county'
Amount- where constructed. I
13b.Disinfection type:�---�
Revised 2-222=Olo
North Carolina Department of Environmental Quality-Division of Water�Reseurces
Form GW-i