GW1-2022-05666_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD(GW-11
For fraternal Use Only:
1.Well Contractor Information:
14.Vi'A7'EA ZUNES:Robert Teague FROM TO DE,SCRiPTSON
rc. rt.
Well Contractor Name i
B&K Well Drilling Inc
10Efr11E1tCitSlIVG aieltsaesedrrells E}ltill it'iK MaTERtn1.
NC Well Contractor Certification Number DL1METEg TffiCKNFSs
FROM TO
2857-A 0 ft. /•d t• 611& I it SDR-21 PVC
Company Name 1611�1VEAG1511Gf1A;Fil$1Nt DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: /—
V O FROM��.L — ft. TO ft. in.
List all applicable well coturrue[lon permits(i.e.U/C.t:orntty,State.Vanmtce,etc.) ft•
ft.
3.Well Use(check well use): L?;SCitEEN
TU
DIAMETER SLOTSIZE THICKNESS MATERIAL
Water Supply Well: ft. ft. in.
'Agricultural �MunicipaUPublic FROM
o (G
in.
in Conlin Supply) Residential Water Supply(single) ft.
al(Heat g
Geothermal S/
[)Residential alWater SuPP�(hae d TDIETHUD
o tm
lnduslriaUCommercial FROM DLTERLt1 Eh(PLAC
Irtieatiun Tt. ft.
Non-Water Supply Well: ft. ft.
DRecovery
Monitoring ft.
tt
Injection Well: -<
Aquifer Recharge �Gro indwater Remediation 19`SAt�1NGRA�?E3 T4CK(i8 t EMPLI MEN METHOD
FROM TO aL,1 .RLIL
Aquifer Storage and Recovery E)Saliniry Barrier� ft ft
Aquifer Test Stormwatcr Drainage
ft ft.
Experimental Technology Subsidence Control "
:O till addict
Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION color. CIS.SOIVrocan a gain sac,ctcl
Geothermal(Heatin Conlin Return) Other(ex lain under T21 Remarks) ft. C tt, j
I. ft.
4.Date Well(s)Completed:`i r if �� Well UN
rt. rt.
sa.Well Location: ft• ft.
c�Lyr.Y til L ' ft. ft..
Facility/Owner ante Facility tDe(if applicable) 1 d L
L S ft. ft. �� r
3i�a� ft ft
Physical Address,City.and Zips
Zip RE3fir'iRK�:$
Parcel iddntifianion No.IPTN) t �` "g Rr
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certif ati n
(if well field,one IaVlong is sufficient) L�r
N Li
Date
Si(7tatutc of Ct:tttficd W�41 Contractor
6.ls(are)the well(s) Permanent or �Temporan
By signing[his tarot.1 h l Co centfi'that tract xrU./s)tv2(were)constnteted in accordance
:rith I5A:vCAe 02C.0100 or 15A NCAC 02C.0200[Yell Construction Standards(Ind that a
7.Is this a repair to an existing well: [3Yes or No coin of this record has heen provided to the vrll orr�ur.
11 this is a repair,fll out know"well construction information and c, lain nc�nature oftit. �3 Site diagram or additional
details:
repair node q21 reniards section or on the bark of this town.
You may use the back of this page to provide additional well site details or we
S.For Geoprobe/DPT or Closed-Looll
p Geothermal Wells having the same constntction details. You may also attach additional pages if necessary.
construction,OnlyIGW-Iisneeded. indicate TOTAL NUMBERofwells SUBMITTALINSTRUCTIONS
drilled:}
s (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: (ft-
to the following:
For multiple a•e11 IBt all depths ifdiJjereat(trample-3@200'and 7 tt,100�
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
lhnate,.level is alurvo casing,use-4-
i 1.Borehole diameter: 6 1/8 (in.) 24b.For infection Wells: In addition to sending the form to the address f well
above,also submit one copy' is form within 30 days of completion of welluf th
Air Rotary constntction to the following:
12.Well construction method:
(i.e.auger,rotary,cable,direct push.dtc.1 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 SuDDIy&infection Wells: In addition to sending the form to
13a.Yield(gpm) Me the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs 1 112 Lbs completion of well construction. departmentto the county health department of the county
13b.Disinfection type: Amount:
where consnactctl.
Revised 2-22•2016
Form GW-1 North Carolina Department of Environmental Quality•Division of Water Resources
es