GW1-2022-03970_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD(GW-11
For Internal Use Only:
1.Well Contractor
formation:
<14.AtATE11:ZOlVES ,;
Robert Teague FROM so TO DESCRiPT1UN ft. oft. SG
Well Contractor Name
ft, ft
B&K Well Drilling Inc .oR. If :
t5 OFITERCAWNG: maifressed R T7MEC- NESs MaTERUL
NC Well Contractor Certification Number FROM TO
ft. 6 118 III SDR 21 PVC
2857-A 0 ft.
atctaaea�tro
::1611VNER -$11iIC':+���1 THICKNESS MATERIAL
Company Name FROaI TO DIAMETER'
2.well Construction Permit#:
ft. ft. in.
Lis(all applicable well construction permits(i.e.LtiC',Cotutty,State.Variance,etc.) ft.
ft. 'in.
...-:::;: >:':ii;::i: ''
3.Well Use(check well use). i.7, )Et,,....:.:::.
FROM TO DIAMETER 'SWTSIZE THICKNESS MATERIAL
Water Supply Well: fL R. in.
_ Agricultural ®MunicipallPublic
Rsidennal Water SuPPIY(lstoo
lc
) . f[.
in:.
Geothermal(Hc mg/Coulie Supply) : 3:<S::i;::;Eh1PLACEMENThIETHU u M.
spared) > o.......
Residential Water Supply
Ind ustriallCommercial FROM To DLTERAL
lrri-ation
Nun-Water Supply Well! g, ft.
Recovery
Monitoring g. ft.
Injection Well:
®Groundwater Remediation
Aquifer Recharge hIATERLAL 19:SAIv#NGRAYEI P4C $ b EMPLACEMENT DIETHOD
ry FROM 70
Aquifer Stor9ge and Recove
Salinity Barrier ft• ft.
Aquifer Test oStormwatcr DTainagc tc.
Subsidence Control
ft
Experimental Technology Zir D1tII;Ll.N0L0C ttaeli'Id"otialslt�etr4 uec�
Geothermal(Closed Loop) Tracer FROM TO ESCKIPTI-N color.herQncss mnoc6ri c ruin size,etc)
Geothermal(Heatin Coolie Return) other(ex lain under#21 Remarks) ft. ft.
ft. ft. Q Cf►
r
4.Date Wells)Completed: 9-1W ell ID# �tS I. 6 -ft.
5a.Well Location: ft. ft. _
CC- ft.ft. ft. o d'n �IC.
Facility)OwnerName FaciGtylD (if applicable)
ft. ft. APR
1
ft.
ft.
Physical Address,City,and Zip
�
Fri
Parcel Identification o.(plhl) d.t 0:5;: it 1 alvt i J 1Yd I
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certifi a���133'8888iittyppyt
(if well field.one ladlong is sufficient)
N W
Date
Sipatun:of Certified Well Contracts
6.Is(are)the well(S)OPermanent or Temporary
By signing this(one.7 herelry certify,that the xellls)was/were)consm+cred in accordance
Yes or No n ith 1.5A NCAC 02C.0100 or 1 iA NCAC 02C.0200 Well Construction Standards and duo u
7.Is this a repair to an existing well: copy of this record has hecn provided m the well owner.
(/'this is a repair,fill o+n lnoxm well cnnstructia:infnnnatinn d c. lain the nature of the
repair under 921 ren+urAs section or on the hack ajthis(one.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
constntction,Only 1 GW-I is needed. Indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled:
well depth below (ft-)) 24a. For All Wells: Submit this form within 30 days of completion of well
9.Total land surface:
For multiple wells list all deptls ifd ii Brent(eramp/e-3 200'and?a 100')
construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11 water level is above casing,use"+"
11.Borehole diameter 6 I8 (in.) tab.For injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
Air Rotary construction to the following:
(i.e.auger,rotary-cable,direct push.etc.) Division of Water Resources,Underground injection Control Program,
W
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR ATER SUPPLY WELLS ONLY:
Method of test: Air Flow 24c.For Water Sunply&Injection Wells: In addition to sending the form to
13s.Yield(gpm) the addresses) above, also submit one copy of this form within 30 days of
Chlor Tabs Amount: 1 112 Lbs completion of well construction to the county' health department of the county
13b.Disinfection type: where consuuctcd.
Revised 1 22-2016
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources