GW1-2022-05557_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
• I
Robert Teague
Gfi.Wi1TERZONIi:.,
FROM I TO DH,CCRTPTTON
Well Contractor Name Cy ft.
B &K Well Drilling Inc
NC Well Contractor Certification Number
2857-A FROM TO DUIMETER TMCKA'ESS MAATERIAL
D ft. Ul ft, 6'/8 tn. SDR-21 PVC
Company Namc
16:7NlVBB G'QR:' ail osed-Ioe '
2.Well Construction Permit#- 1-,3 c) FROM ft. ft.TO DIAMETER THICKNESS MATERIAL
List all appiicab/c well construction permits 1i.e.UIC.Comm+,Slate.Variance,etc.)
�^•
f[. ft,
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipallpublic ft tt in.
)Geothermal(Hcating/CoolingSopply) Raidcntial Water SuPPIY(single) ft ft in.
:)Industrial/Commercial
CSI en'al Water Su
pply(shared)hare d
)
::I. ALATERi EMpLAC X NT ME .A THOD& MOUNT
irrigation FRROM TO
Non-Water Supply Well: ft. ft. E.�t'
Monitoring ORccovrn fc. ft.
Injection Weill: ft. ft.
Aquifer Recharge [3Groundwater Remediaion
Aquifer Stor2ge and Recovery Salinity Bather FROM I TO !1LATERLAL EMPLACEMENT METHOD
�Aquifcr Test oStortnwarcr Drainage ft. ft.
Experimental Technology [3Subsldence Control ft. ft.
Geothermal(Closed Loop) Tracer8:}3RI1::I3PIGf,Q. aftaclradd?tiiudsbrefs:
FROM TO DESCRIPTION eobr.hardness,soiUrock m sac.ete.h
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. - t.
4.Date Well(s)Completed: Well ID# ft• a-� ft. co 0
ft. ft.
5a.Well Location:
ft. ft.
ne] r y� ft. ft.
Fay /Owner Name Facility lD'(if applicable)
ft. ft.
7-6 LL /'�{��1('1 SA Cl.� ft. ft.
Physical Adds.City.and Zip
Address. ...................................w...........
:iC::x
u r YeeU a ZU72
County Parcel identification No.(PiN)
�Pr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
fjrw
(if well field,one lat/long is sufficient)
N W
Si_ptaturu ofCertiflud Wcll ntractor Date
6.!s(are)the well(s)oPermanent or OTempnrary
liy signing thin form.1 hereby certify ttiat the xrll(r)was N-cre)cown-ucred in accordance
7.Is this a repair to an existing well- [)Yes or Nowith 1 SA NC.dC 02C.01 t70 ur ISA NCAC OIC.O20t7 Well Cunstracriun Standards and that a
/f thin is a repair,ill ota knotty well construciion infarmotion Avlain the nature of the cop}'of this rerord itas been provided to the Fell our
repair under 921 renurrks section or un the bark of this funn. 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/DPI or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 4 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: q, (ft-) 242. For All Wells: Submit this form within 30 days of completiou of well
Fnr tnulaple ur/Lc lw all deptlu i(different(example-3(-2"'200'and 2C1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
fl'warer level Lr above caring,mve••+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) lib.For Iniection Wells: in addition to sending the form to the address in 34a
Air Rotary above.also submit one copy of this form within 30 days of completion of well
12.Well construction method. construction to due following:
(i.e.auger,rotary.cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mai!Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) V� Method of test:
Air Flow 24c For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well construction to the county health department of the county
where constructed.
Farm GV.'-i North Carolina Department oFEnvironmental Quality-Division of Water Resources
Revised 2-22-2016