GW1-2022-03924_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW'l)
For internal Use Only:
1,Well.Contractor Information: I t yrAf ER>ZQNS
Robert Teague
FROM TO :.. DE.SCR[P •ON .
S S rt.
Well Contractor Name ft.
ft
B&K Well Drilling Inc otza1 If:,.,: MATERIAL
IcotsrERc;sll�o ;;� TmclzvEss
DIAMETER
NC Well Contractor Certification Number FROD[ TO to SOR-21 PVC
0 ft f '/ ft. g Ila ..;i
2857-A r (
.lb+'ll'NE R ' r' DIAMETER THICKN
TO ESS MATERIAL
Company Name 1 ^I — FROM ft. fL in.
r �+
2,Well Construction Permit#: is in
List all applicable well cortso crion permits(i.e U1C.Lours v,Store.Vurswae,ctr I ft.
MATERIAL
ICKNESS '
3.Well Use(check well use): FROM TO DIAMETER SLOT SIZE TH
Well: fL ft. In.
Water Supp y [3M micipal/Public
Agricultural ft. th.
(Sin-
IC)lc ft
RLSid°ntial Water Supply(st � ) .
GcothcrTnal(Hcatmg/CoOlmg Supply) ? E�fpLneEMENT r>ETaoD& sto[t>r7
Residential Water SuppIvshared)- ( ': T To ntetERr�r
rAquifer
Commercial FROM
tt- ft.
Supply Well: it. tL
ORecov'ery
g ft. tt.
ell:
ticable
Groundwater Remediatton ly:SAiVaIGG ELY IC EMFL[cExEVT NIETHOD
echarge FROM TO MATSalinity Bamer fit. ft.torsge and Recovery oStormwatcr Drainage
AquifCTTcst PJ ft. ft•
Subsidence Control
..ttBClf 8ddi$iihek-'s3ee4' s m size.tier .
Experimental Technology 24:DRTi GLOF,. oEaCRlrrloN color. ,rdncss solvrocl ri
Tracer FROaI 70
Geothermal(Closed Loup) ( ft. 1"� ft. 1 r
ex
lain under#21 Remarks)
Geothermal(HeatinPJCoolin Retltm) ft C L'
4.Date Wells)Completed: Well Well ID# ft
a cs . 3 �
Sa.Well Location:
fit. fit.
�''���� ft. . fit. a-
Facility IDm(if applicable) ft.
Facility/Owner Nance
Physical Address,City,and Zip 2; RFtli!tlKS
L Parcel Identification No.tPiN) JIn;,r,;t �,yc_�4'.�4J
County �„��.�>� .
5b.Latitude and longitude in degrees(minutes/seconds or decimal degrees: 22 Certification,
(if well field,one lat/long is sufficient) 3 .-I l.( 2—a
W
r - - Date
$iLnratua:of Certified W ell Con actor
6.IsOre)the well(s)ISPermanent or Temporary
in Brthr15ANCAC01C.01r00corISAtifYthal theNCACO2C.02100/W IlCutntruchutSurndardarrnd Itata
o well: 13Yes or No copy of this record has been provided to the xell o"ner.
7.Is this a repair to an existing �d
IJ'this is a repair'.ill aru broww well cnnstruction infnnnatiar an explain the nature Of the 23 Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
repair urtdrr r21 renua•ks secHun ur on the back ujrhis(urrn.
construcZion details. you may also attach additional pages if necessary.
S.For Geoprobe/DPT�o�Cs ne ded olndGeatebTOTAL N U YLBER of welermal wells having the ls
construction,construction,only SU BN117'TAL INSTRUCT 1 ONS
drilled: 3 W
(ft) 24a. s form within 30 days of completion of well
ForFor A�ells: Submit thi
9.Total well depth below land surface:
For multiple wells ttst all depths ifdiffereni(trample-3�200 and 2@100') constnun Divos ontoflVvater Resources,Information Processing Unit,
(ft)
10.Static water level below top of casing:40 1617 Mail Service Center,Raleigh,NC 27699-1617
!j'warer revel is above casing,use"+
. 24b.For inie e��s in addition to sending the aysfor to the address f : a
II.Borehole diameter: above,also submit one copy Of this form within 30 days of completion of well
6 �$ (in)
12.Well construction method:
Air Rotary construction to the following:
(i.c.auger,colnry-cable•detect push,etc Di�isiorl of Waver Resources,underground injection Control Program.
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
du"Z,the folul to
` S Method of test•. Air Flow tic.For W °reply&Injection Wells: In addition to s�itthin 0 days of
13a Yield(gprn) the address(es) abol e, also submit one copy of this form
Chlor Taus 1 1/2 Lbs completion of well construction to the county health department of the county
Antaunt:
13b.Disinfection type: where constructed.
Revised'_-22-2010
North Carolina Department of Environmental Quality-Division of Water Resources
Form OW-1