GW1-2022-05665_Well Construction - GW1_20220608

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague t .W. R:zolvr s .>.:
Well Contractor Name FROM TO DESCRnMONVC
B &K Well Drilling Inc
3.t-1,N0 a. .. >�
NC NeI1 Contractor Certification Number ..;���
15i:fH#'fEiL�!`AS1t1TG
2857-A FROM I To DLIMETER I THICKNESS K-ITERIAL
Company Natnc 0 ft c> fL 61/8 to SDR 21 PVC
1�51NiYSBG�Sf�:E)R'FU13 �atit:fasEd ,
2.Well Construction Permit#: 13 S 1 `"( a FROM TO DIAMETER THICKNESS MATERIAL
Us(all applicable x:ell construction permits li.a.UIC,Coutgv.State.Variance,air.) ft• ft. in.
3.Well Use(check well use):
f[. f[. in.
Water Supply Well: FROM TU DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipa✓Public fL ft. in.
BGeothermal(Hcating/Cooling Supply) Residential Water Supply(single) rt ft. in.
lndustrial/Commercial []Residential Water Supply shared) ........._11 .....
Irrigation FROM I To NL1.TERI&L EMPLACENIMN-T NIETHOD x AMOtrNT
Nun-Water Supply Well: ft. It.
Monitoring IoRecovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
>I9::SAiVflIG3Cnt'EE..P4E';1�Gf"'lcaHle ,
Aquifer Storilge and Recovery DSaliniry Barrier FROM TO NLATERLAL EMPLACEME-rMETHOD
PAquifcr Tcst [3Stormwatcr DrainaL•c ft. ft.
P'lExperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer Z&.8173j 1tINGLOC:afEachaddiiii+he}s
Geothermal(Heating/Cooling Return) Other(explain under T21 Remarks) rRoM To DESCRIPTION color. rt ss WHIMCk to '_ to size.ctc.)
tt. it. l
4.Date Well(s)Completed:s �'� Well ID# , ft' YU
5a.Well Location: L
• /-UTZ r r\ L L
Facility/Ow er Name J Facility ID#(if applicable) ft. ft. 07-::�"'INI t
ft. ft.
1 cl'l O� P j_r'1-�y Y'� �Y��e "
rt. rt.Sc)���
Physical Address,City,and Zip �— N o S 2022
.'23:RfatiiAR lf5
-� Cam G for s l t'rc Wart tg Unti
County Parcel Identification No.(PM)
t V �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)IRPermanent or JDTemporary Sigutur:of Cenificd Wall Contracu, Datc
By signing this torn.I herelry certify that tire xrlks)was(x,cre)constructed in accordance
7.Is this a repair to an existing well: E)Yes or Na ,'ith 1 SA NC:AC 02C.O100 or 13A NCAC 02C.11200 Wall Cansrru iian St(tndc r h and that a
I/'this is a repair,ell ow know well construction infnnnadort n arp(ain the nature of the copy of this record has been prnvidcd to the x-ell ott;-ner.
repair under#21 remarks section a•on the bark ojthis form.
23.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 gage to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: A SUBMITTAL INSTRUCTIONS
9.Total well dept below land surface: Ift) 24a. For All Wells: Submit this form within 30 days of completiou of well .
Fnr multiple wells list all de/udzs ifdifferent licrarnple-3�?00'and 2@I001 COIIStrtChOn[0 the fO110vvurR:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If tearer level is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For infection 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 the following:
(i.e.auger,rotary,cable.direct push.etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Dian Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) � Method of test. Air Flow 24c-For Water Suably&Ltiection Wells: In addition to sending the form to
the address(es) aoovc, also submit one copy of this form within 30 days of
13b.Disinfection type: Chloe Tabs Amount- 1 112 Lbs completion of well con,tructiou to the county health department of the county
whcrc constuctcd.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016