GW1-2022-05650_Well Construction - GW1_20220610

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
L.Well Contractor Information:
Robert Teague t <vIrAli;:zol+rl5
Well Contractor Name FROM`'�Z Sft. TO DESCRIPTION�,� rt. tl
B&K Well Drilling Inc ` rt 4 75rt. I
NC'Well Contractor Certification Number
1rti0iffER'GASING. ,atnitd= 113`f3K'i31!1�f2 if:,
2857-A FROM TO DLAMETER THICKNESS M4TERIAL
p ft. ft. o 1/8 In- SDR 21 PVC
Company Namc
// , qq � J 7:b<>LnN�Rf:�$f1�E�E�`IU$1�tG: maticlosed-loti'
2.Well Construction Permit#: W D�� r .S �1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well co,ssimcdon permus fi.e.UIC.Cotnt(v,State,Variance,etc.) ft. fL - in,
3.Well Use(check well use): ft. tc. in.
Water Supply Well: FROMirEEN'; E
FROM TO �DIANI METER I SLOT SIZE ITHICKNESS M4TERIAL
Agricultural E]MuaicipaUPublic fL ft. io-
r-IGcothennal(Heating/Cooling Supply) rIRLidcmial Water Supply(Single) fe fL In
15 Industrial/Commercial esidenrial Water Supply(shared)
ISS GROi3. ..
_711irrization FROM TO NATERL4L EMPLACEMENT NEETHOD 8 AMOETNT
Non-Water Supply Well: ft. iL
Monitoring IoRecot'ery• ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
T9::S�tiYD2Glt��-EE 1+4C:�.fit' ' licabte T
_s..
IpAquifer Storage and Recovery :Saliniry Barrier FROM TO NL4TERL4L EMPLACEMENT NLEHOD
C3Aquifcr Tcst [3Stormwatcr Drainage ft. ft.
PExperimental Technology Subsidence Control
nGeothermal(Closed Loop) [)Tracer 213: RiIEsiikGl,OG:attaeh.adiGeitks> s
FRO NI TO DESCRIPTION color to ness,w k to tarn size_cm)
Geothermal(Heatin Coolie Retur ) Other(ex lain under#21 Remarks) ft '3 ft � C
4.Date Well(s)Completed:` ( '�` Well ID# ft' ft.
5a.Well Location:
�� � f[. ft.
'fi / awl T
Fac
il
ity/0w erName Facie[ #(ifapplicable) ft. ft_
y /�LD P �IYL f.
Physical Address,City.and Zip ft. ft.
L�ocr I o-46 1 o,3 815 9—
.23'RFtttAttKC : .
County Parcel Identification No.(PIN)
n ofsra tgtM9 Ulm
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DIX00013
(if well field,one ladlong is sufficient) 22.Cerh n-
rl
? _31,
6.1s(are)the well(s)oX Permanent or []Temporary Signature of Certified Well C,ntractur Date
By signing this form•I hereby certrjy chat the we11(s)was(x•cre)com micted m accordance
7.Is this a repair to an existing well: [3Yes or No ith 1?A NCAC 02C+0100 or 154 NCAC 02C.0200 well Construction SrandardJ and that u
J this is a repair,ill out known well constm,ction information ars explain the narare of tine copy of this record has been provided i the well on;ur.
repair und(a-#21 remarks section or on the bat•k of this funs.
-3.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constniction,only I GW-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a. For All Wells: Submit this form within 30 days of completion of well .
Fnr multiple wells 14q all depths ifdlffe,enr(tranple-3!_x-100'and 2 cci 1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
ywvter level is above casing,tece-' 1617 Mail ServiceiCenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ 24b.For Iniection Wells: in addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rosary.cable,direct push-etas
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY HELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Li 0 Method of test Air Flow 24c_For Water Supply&Inie tion Wells: In addition to sending the form to
the address(es) aaove, also submit one copy of this torte rvithih 30 days of
13b.Disinfection type:
Chlor Tabs Amount: 1 1/2Lbs coatP letiou of well consrructioulto the county health department of the county
where eonsnucted. g
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Rev-,sed 2-22-2016