GW1-2022-05664_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague
FROM I TO DES 71ON
Well Contractor Name ft. r1 6 ft
B &K Well Drilling Inc sL ft. d ft.�165 .............
NC Well Contractor Certification Number r
FROM TO DIAMETER THICKNESS MATERIAL
2857-A D fL fL o 1/8 hL SDR-21 PVC
Company Name 76:>11 V8SE ksll! :flR M
slosea-wa
i ) /;� /• FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#:l h�'1( : 1�I� {t fL in.
List all applicable well construction permils(i U C.Comm,Stare.Variance,etc.)
ft. f[. in.
77
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SWT SIZE THICKNFSS M.ATERI AL
:JAgricultural oMunicipal/Public ft_ ft. In.
)Geothermalm
(Hcating/Cooling Supply) 19 Residential Water Suggly(s .olc) ft ft- in.
lndustriaCommereial Re sid enua I
Water Supply
V(shared)re d
)
FROM TO ISL�TERIAL EMPt.nCEMEhT METHOD&AMOCfi'T
Irrigation ft. ft.
Non-Water Supply Well:
Monitoring [3Recovery ft, ft.
Injection Well: ft. ft.
g r]Groundwater Remediation
Aquifer Recharge
;::79:.SAiVIJ1C�t:4Y"EE.P4CLCGf 13cab1e <.: : ... ,;...
:......
Aquifer Stor9ge and Recovery' [3Saliniry Barrier FROM TO DL>TERL>L MPLACEMEYr DlETdOD
E
PAquifcr Tcst [3Stormwatcr Drainage
ft. ft.
ft. ft.
Experimental Technology Subsidence Control ..,..,:.
Geothermal(Closed loop) OTracer
':Y$i'BRA.1;3�rs'i�OC'4ttaclta8d'iHeiud.ehee�:�'
FROM TO DESCRIPTION rnbr. nos spiVnxk gain size.ere
Geothermal(Heatin Coolin Rettun) Other(explain under#21 Remarks) © ft t . {t, B
ft. ft.
4.Date Well(s)CompletedS_1 C- Well ID#
ft.
5a.WellLocati L f.
n n Vielz-
Facility/OwnerNante FaciLry 1D�(ifappli-ble)
^' A ft. ft.
ft. ft ,1UN 0
Physical Address,City.and Zip
> ::
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Cer' ti
(if well field.one laUlong is sufficient) -
N W
iLrtatutc of Ccni6cd Convector
Deta
6.is(are)the wed(s)opermanent or Temporary
By signing this form.I hereby certfjy that the xel/trJ ions twrrcl consrrtrcted in accordance
existing well Yes or-gNo ,ith 15A NCAe 02C.0100 or 114 NCaC
7.Is this a repair to an existing OIC.0200 well Con truer ern Standards and that itl(tluh is a repair,ell on;b+o»n well ennst ucliou infannatia+ n lain the nature of the copy of this record hat been provided to doe well owner.
rrpuir under 421 renuu•ks section or on the buck of ihis.funn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT 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: r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓ O —(ft-) 24a. For All Wells: Submit this form within 30 days of completion of we .
Fnr multiple uelk lLsr all depths if cent(ucarnpfe-3 ?UO'and 3Q/001 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
1l'rs'atPt•level&above ceWns,we
11.Borehole diameter: 6 118 (in.) 24b.For injection 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.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 Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) the address(cs) above, also!submit one copy of this form within 30 days of
L: 1 1/2 Lbs corn letion of well construction to the county health department of the county
13 AntODII
b.Disinfection type: Chlor Tabs wbc constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016