GW1-2022-05663_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD(GW-11
For Internal Use Only:
1.Well Contractor information:
14 WATER ZOO DESCRTP7 fO v `.
Robert Teague FROM To
oft, i
Well Contractor Name I
ft
B &K Well Drilling Inc
n. f
oli: 1�}ER tf
-;45-OUTFERGASiNCE :atatii=cased cre115 TffiCK MATERIAL
DIAMETER ! NESS
N('Well Contractor Cenificatiun Nvmbzr FROM 70 itL PVC
2857-A ft. 51I8 SDR-21
M ATERIAL '
16,li�IV£KCVS11�Gfi1R'SEETER too
THICKNESS
Company Name !7 FROM TO
f[. in.
2.Well Construction Permit#:
ft.
crion permits li.n. 7C.Counm,State.Yanw+ce,etr.l ft• in.
Lisl«(1 upp h�cablc well consrru ft. i --
3.Well Use(check well use): :1.7,:SCRE£'
FRONT I TO DIAMETER SWT SIZE THICKNES5 MATERIAL
Water Supply Well: ft. I ft. In.
Agricultural MuniclpaL Public
ingle)
esidcnLial Water Supply(s fL
ft 1°
Geothermal(Heating Cooling Supply) R Stdential Water SUDPlv(sharel) 18.GROCf
Industrial/Commercial `L,LE�� gy1pLACEME ST�LETHODg LMOLfi7
FRONT I TO
ft- i ft-
1RIgaUUn
Nun-Water Supp �
ly Well: ft. ft.
Recov'ery I
A4onitoring ft. tt.
injection Well:
Aquifer Recharge [1Gloundwater Remediation- 19'SANDIGRAVEL P (if ACK a 'RULe) ENT PLACEMEYT MET HOD
FROM TO AIATERLA
Aquifer Stor2ee and Recovery
oSalinity Barrier ft. ft,
Aquifer Test [3Stormwatcr Drainage ft ft
Subsidence Control
,ExperimeotalTechnology 28DRIlL1a1G1OG tt$ckad ° is iF
Tracer FROM 70 DESCRIPTION color, ness,soUroc6 n rvin slZq ete.l
(}eothermai(Closed Loop) I,
Geothermal(HearinvCoolin_Return) Otaer(ex lain under T21 Remarks) ft.ft,
ft.
Lt.. (-.`:2-A Well ID#
4.Date Well(s)Completed: 3 li
R. � ft. j,�,Y-
�i
Sa.Well Location: / ft, ft.
11)n l LS ke ft. ft.
�i 't 11 Facility LD;,(ifapplicable)
Fac :Ow'ne:\a ft.
1iR
1 1 \ l� 51 It lit/ 1 W\ e
ft. ft
physical Address.City,and Zip :21;'REIILaiRKS<;
CGS 1,C int `''PrcLslg Un;v
.1100.
Parcel identification NO (PIN)
Couny
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 CeTffi
(if w'cll field,one lat/long is sufficient)
W �1
IN i Date
sipwinj t:of Cenified Well Cy(tGactni
6.ls(are)the w'ell(s)oPermanent or E)Tempnran'
ey signing this(onn•1 hcrrlro crnifv that me vel(Bi'was Iwrrc}coturntncd in accnrdmtCc
.ril.h 1`._VC.4C 02C.0100 or 1 iA.NCAC 02C.0200 k'el/Construction Standards and Mill n
1 e5 nr p--y co{n-crthir record has beer,provided to the reh o rner.
7.is this a repair to an existingvvell: \o
(fthe,i.s a repair,fill out blown well constructs i ortna!;rtr and rxpfarn the nature ofthe �3.Site diagram or additional well details:
rc<puir+mdta-=21 renrur!•s sre:'iun ur on the honk u(t %s/onr..
You mad use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
constntction,onlyIGW-I is needed. indicate TOTAL NUMBER ofwells SUB,NIITT.ALIN$TRUCTI ON,S
drilled:
5 �� (ftJ 24a. For All Wells: Submit,this form within 30 days of completion of well
9.Total well depth below land surface: constnution to the following:
Fnr n;u/r,'ple+yells lLgr all depths ifdijlercn!r6,ratn(�Ir-S:a.-'0O'and 2C1f Ili
')
40 Divis
ion sion of Water Resources.information Processing Unit,
10.Static water level below top of casing: 1617 mail Service Center,Raleigh,NC 27699-1617
;1'.vare,-lev'ei is above Casing,ttsr"-
ition to se
(in.) ''-4b.For injection Wells: In add the form to the address in'_4a
6 1l8
17.Borehole diameter: hin 30 days of completion of well
aboxe. also submit one copy this form wit
Air Rotary construction to the following:
12.Well construction method:
(i.e.auger,routy.cable-direct paSIL elc.I Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
[133a.
WATER SUPPLY WELLS ONLY:
Method of test: Air Flow _ 124c.ForWater Sunaly&infection Wells: In addition to sending the form to
Yield(gpm) the addresses) above, also!subtmt one copy of this formwithin 30 days of
Chlor Tabs Lbs completion of well construction to the county health department of the county
Amount:Disinfection type:�— wln,c consLrvctcd.
North Carolina Department of Environmental Q'aalitY•Division of Water Re.ources
Revised 2-22-2016
Form CW-I