GW1-2022-03929_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only':
1.Well Contractor Information:
Robert Teague FROM TO DHSC'RTPTION
rj S rt
Well Contractor Name ft.
B&K Well Drilling Inc
jr::; ERCA5iivG ivatfi- 11s 0[L:1 11!1BR MATERIAL
NC Nell Contractor Certification Number FROM 7U DIAMETER' Tl�ctO�Ess
11
2857-A 0 ft. ft. 61/8 In SOR-21 PVC
16?11913irR-G SIN G � � MaTER1AL
Company Name DIAMETER THICKNESS
FROM TO
2•Well Construction Permit#:
f[.
List all applicable well co+rsnttcdon permits(i.e.UiC'.County.State.Yanmtce,etc./ fe ft in
_. .
3.Well Use(check well use): -
17:S4ME€N :I .. ..". sWT SIZE THICKNESS MATERIAL
1 Well. FROM TO
Water Supp y fL tt. in.
Agricultural �MunicipaUPublic
Olin Supply) Rcsidcridal Water Supply'(single) fL ft
un Co pP
in.
h anal(Hca � g
Goo . . ....
t idzntial Water Supply(shared) 18'GIYQIiT .'.. '.
Enipr ncEtt�NT DIETHOD&AMOUNT
IndustriaUCommercial FROM TO atATERi+I
Irrigation ft. fL
Non-Water Supply Well: ft. ft
Monitoring E)Recovety
Injection Well:
Aquifer Recharge E3GroundwaterRemediation ig.;5}1iNf)IGRAVEi.44GK'Gf ticatlr grytpyperMFNThIETHOD
FROM TO 1L4TEE
� Salitliry Bather ft. ft.
Aquifer Stor2ge and Recovery
Aquifer TcstStormwatcr Drainage
Subsidence Control
ft tt.
Experimental Technology 28URTLIING:I:OG trash adonel sllcetsA::,neck
Geothermal(Closed Loop) Tracer FROM To DESCRIPTION color.hard s somrocl n n,mslze ctcT
Other(ex lain under#21 Remarks) jc g ft. i
Geothermal(13eatin Coolin Return) 11Ve llID# V
ft. r
4.Date Well )_Js)Completed: e ft. L16 5
Sa.Well Location: L JG ft.
r['�;.(�((A C�•�it tt. ft.
FaciGrylD".:(ifapplicable)
Facility/ nerNato
v 5A c;��C5IV ft. ft
physical Address,City.and Zip
�rf-'i+�(•
Parcel identification No.(PiN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Cer catio
(if well field,one latllong is sufficient)
N
Date
t eluro of CcRificd Weil ontracUtt
6.ls(are)the well(s) Permanent or �Temporan'
By Signing this(onn,T hel o tract(y'[ha[the xeH(s)w2c(were)communed in accordance
gam{ Frith I5A NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction SumJunls rrnJ that n
Yes ory No coy.o(this reenrd has heen provided to the xrll o,rner.
7.Is this a repair to an existing well: lain the nature o%the
fl this is a repair,fill our knoww well cnnslntc[iW+information a 23.Site diagram or additional wen details:
repair under 921 remard-s section or on the buck ojthis(urn. to provide additional well site details or,sell
You may use the back of this page
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
constntction details. You may also attach additional pages if necessary.
constntction,only I GW 1 is needed. Indicate TOTAL NUMBER of wells Sljl3M ,AL INSTRUCTIONS
drilled:
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple mellc lw all depths i(di((erent/example-3@4,100'and 2 a,100')
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
1l+rarer level is a/,ave casing,use"+
11.Borehole diameter: 6 1/8 (in.) 24b.For Tniection Wells: In addition to sending the form to the address f well
above.also submit one copy Of this form within 30 days of completion of well
Air Rotary construction to the following:
12.Well construction method:
(i.e.auger,rotary,cable.direct push,etc.) Division of Water Resources,Underground injection Control Program,
C 27699
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,N -1636
(�Z Method of test: Air Flow 24c.For Water Sunaly&Tniection Wells: In addition to sending the form to
13a.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 consnucccd.
North Carolina Department of Environmental Quality-Division of Water Resources
Revised'_-?_'-''_Ol o
Form GVJ-1