GW1-2022-05638_Well Construction - GW1_20220610

For internal Use Only: ,
WELL CONSTRUCTION RECORD (GW"11
1,Well Contractor information:
1A�iA1El}ZONL�' DESCRIPTION
Robert Teague FROM TO
�S S rt. 3 rc
1Ve11 Contractor Name
it. ft 4
B &K Well Drilling Inc --
li UEJ1ER4CAMNG: maltfcasedsrelts flgi 11 �.—.ER1AL'
NC Nell Contractor Certification Number TO DIAMETER f 1HIChNESS
FRODI
2857-A p ft. ft. 6118 11"', SDR-21 PVC
aR>� ric' mat�tosedtoe
16 IN1+fi RGi Company Name FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
fist all applicable xr11 co/[struction permits(i.e.U/C.(omt[v.Srute.Vuna,rce.crc.l ft. ft.
_ .
3.Well Use(check well use): I:7,$CREEh MATERIAL
FROM TO DIAMETER SW7 SIZE THICKNESS
Water Supply Weil: �VlunicipaUPublic IL ft. in.
Agricultural ; in.
a f4
lCoolin Supply) esislcnaal Water Supply(sun�lc) ft.
Geothermal(Hcaung g Residential Water Sup lv(shared)
p IS::GRt?i3T>`::` PL,TERLIL EhfpfACEMEN?METHOD&.kMOUN?
industrial/Commercial EROIM To
ft-
lrriaation
ft.
Nun-Water Supply Well: ft. ft.
Recovery
.Monitoring ft. ft.
injection Well:
[3C,roundwater Remediation Gl2AyE1 ly SAi�pf P2GKaf:
Aquifer Recharge 'to
tliiible EMpLaceMEvr ntETHcrD
FROM TO
Aquifer Stor2ge and Recovery MATE
Salinity Barrier ft. ft.
Aquifer Test []Stormwater Drainage ft.
Subsidence Control
ft
Experimental Technology 1 Zg gggUAN�GLt)G ttaeh nEsCRI TION +o'neces+
tf��yTracer FROM TO DE,SCR1P710N br.h ess,snlV,oc1.n io size,tail
Geothermal(Closed Loop) I.�
Geothermal(Heatineicoolin Return) Other(ex lain under R21 Remarks) ft. _ ft.
ft. ft. 0-•
4.Date Well(s)Completed: µ'ell 1D# ft.
5a.Well Location: ca ft. ft.
Tr � / b ft. ft.
Ftyw � t Facility lDR(if app
coer ame
ft. ft.
oil tc. i
physical Address.City.and Zip r� D i;g$14ihRKS.':.
parcel ldentific:rtion NO.(PIN) ino t V�,��Q;VOG
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 2 CQ tt
(if well field.one IaVlong is sufficient)
)1at�
Sikmaturo of Certified Wo Cuntrectnr
6.ls(are)the well(s)OPermanent or C)Tempnran'
By signing this form.1 hereby certify,that the vrl!!s),vnc(x'ere)ennsrn¢red in.accor arse
+rilh I.SA NCAC 02C.0100 w 1 SA NCAC 02C.0100 i9'eU C urtstructiun StanJurJs and that a
7.Is this a repair to an existing well Yes or No co of this record has been rnvided to the veil owner.
lrthis is a repair,ill out knower well construct ia:infnnnatinn d lain the nature of the �3.Site diagram or add'1tioDal well details'
repair under,21 rvma,_ks section w'on the back of this fur,n.
You may use the back of this page to provide additional well site details or well
if necessary.
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells SU611ITTAL INSTRUCTIONS
drilled: r7
9.Total well d pth below land surface: > -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple evells list all depths if different(example-3/a'-'tin'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
1('evater level Li above cursing,use
1/8 _(in.) lib.For infection Wells: In addition to sending the form to the address in 24a
6
11.Borehole diameter: 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: k
(i.e.auger,rotary,cable.direct push,etc.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Method of test. Air Flow 24c.For Water Sunply&hiiection Wells: In addition to sending the form to
13a.Yield(gpm) the address(esl above, also subt one copy of this form within 30 days of
Chlor Tabs Amount: 1 112 Lbs completion of mi
well construction to the county health departinent of the county
13b.Disinfection type:�— where ;onStlltctcd.
Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources
Form GV'-1