GW1-2022-03971_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD
For lntemal Use On1Y:
1.
Well Contractor Information:
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Robert Teague FROM T DESCRTP ON
rt.
Well Contractor Name
B&K Well Drilling Inc ft• ft.
1 ti 1)U l IS1bGii51#YG ntutta 69ed:1Yelh E1K3 iE MATERIAL
NC Well Contractor Certification Number FROM To nL[METER Tg1CKMS
2857-A p ft. ft- 6 118! im SDR 21 PVC
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Company Name 1Si1N�11r1tG S11�Gam: DPI ETE.R THICKNESS MATERIAL
1.Well Construction Permit#:
ft. TO ft. in.
List all applicable Well Construction permits(i.e U1C,l oratry,State.Variance,etc.) FROM ft It. in.
3.Well Use(check well use):
FRijm TO DIAMETER SWT SIZE THICKNESS MATERIAL
Water Supply Well: ft a. in.
_ Agricultutal �MunicipaUPublic
Residential Water supply(single) ft. ft. in.
Get c anal(H satin Cooling Supply) PP Y g )
d tar [1 ) 0 s s:c&.1M
Ater Supply( �.���i�G"lZDrtJif�<$s ;iii: i;;istETaUD
IndustriaUCommercial Residential W PP Y t8• DLATERLIL EMPLACEMEhTD
FRU�I To. ..
rAquifer
ft. ft.
Non Watery Well: ft. ft.
�Recovt ry
ft.
Injection ft.
Iicahle
e GroundwaterRemediation -+GCS EMPI.ACEr,E`tTMETHOD
FROM OAquifer torge and Recovery ElSalinity Barrier ft.
ft.
Aquifer Test �Stormwatcr Drainage
ft. ft
Experimental Technology oSubsidence Control .... .......
-
Tracer 2�D1tII LING' OC DEscRtrTtos toBr n� otur«t nun stzacmt
Geothermal(Closed Loop) FROnI To
Geothermal(Heatin Coolie Return) nMer(explain under#21 Remarks) ft. 3 tt A
4.Date Well(s)Completed: —bell ID#
3
ft. ft.
5a.Wen Location: ft ft
ft. ft.
Facility/owner Name Facility I.D#(if applicable)
ft. ft.
s
Physical Address.City.and Zip
CCR.IC�Q )I
APR:> 2.:.202�,-
Parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certifrc n: -yl !�� t
(ifwell field,one lat/long is sufficient) I{�eda I r+-)'' ,
N W
Date
sifmaturc of Certified Well Conti
6.ls(are)the well(s)opermanent or 13T n'empora
Bs signing this jonn,1/rerefry certify,that the xrllLs)was!were)totsstrtecrd in accnr ante
ith 15A!VCAe 02C.0100 ur I.iA NCAC 02C.0200 Well Cumn'u"Hun St
and that it
7.Is this a repair to an existing well: Aite or ONn co ofthis record has been rovided to the well owner.
pr p
ljrhia is a repair,T[l out known well ennstructonnation and explain the nature ofthe dditional well details:
repair under#21 renuais section ur un the back of this furor. 23.Site diagram or a
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.
construction,only W-lisneeded. indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled:
9.Total well dept low land surface: (ft-) 24a. For All Wei Submit this form within 30 days of completion of well
For multiple mellc lut all depths ffdifferent(csanple-3ra+?00'and Ida 10l1')
construction to the followin,g:
40 (ft} Division of Water Resources,Information Processing Unit,
Ill.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
y'wvter leve/%s above casing,uses"+"
11.Borehole diameter: 6 1 I$ (in.) 24b.For infection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this foml 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.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: Air Flow 24c.For Water SuDDIy&Infection Wells: In addition to sending the font to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type: Chloe Tabs whet constructed.
North Carolina Department of Environmental Quality.Division,of Water Resources '_
Revised -32-2016
Form GVd.I