GW1-2022-05667_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD(GW-11
For Internal Use Only:
contractor Information:
1.Well C ,
.DESCRIPTION
Robert Teague FROM TO
ft. 6Well Contractor Name tt. 1
B&K Well Drilling Inc ft. rt.
1 :orrrElicnsiNis ainiti-used«ur©[t:t< t rf
NC Well Contractor Certification Number D5111ETER y Tffichlr�Ss MATERIAL
FROM i0
2857-A 0 ft. ft- 6 118 s0R 21 PVC
?j6,11!1NER�C:V511GE32t:'f.I. 1CtG -tLetrdal closed=loH - .MATERIAL
Company Name TO* DIAMETER THICKNESS
� FROM
2.Well Construction Permit#:
r r' l E---�— ft. ft. in.
List all applicable xell construction permits ii'a' I Comm,State.Variance,etc.) tt• ft. ;in.
X.
3.Well Use(check well use): aq �T MATERIAL
FROM TU DIAMETER LOT CIZE THICKNESS
Water Supply Well: fL ft. in.
Agricultural �Municipal/Public
tin Conlin Supply) Residential Water Supply(single) ft- In.
ft. .
Geo
thermal(Hca g/ g
Residential Water Supply(shared)
lndustriallCommercial FROM TO !\LkTERLkL EN1PI ACEMEN'T p1ETHUD 8.1MOCT74r
Irri ation tc. ft.
Nun-Water Supply Well: g� ft.
Recov'ery -
Monitoring ft.
it
injection Well: e}
Aquifer Recharge E]Croundwater Remediation 19 GR9:VE PACK. EttlPLacentEvr METHOD
q
FROM TO AL4TERML
Aquifer Stor#ge and Recovery �Saliniry Barrier ft.
- ft.
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
�pggTracer 28DRIIfdNG'I:OG ttacli'D� toPTk1ON1 has solurce6a a ruinstzc ctel
Geothermal(Closed Loop) L 1 FROM To
Geothermal(Hearin Coolie Return) er(explain under.; Remarks) ft• ft.
Oth
4.Date Well(s)Completed:Z,t L a Well lD#
fa.
Pan.,i Nt �r ms ft.
l
Sa.Well Location: C) tt.
ft. tt.
Facility/Owner Name Facility LD#(if applicable)
ft. tt.
se ft ft. h.
Physical Address,City l 3,and Zip yi RF}ti3RtcS
1
1.l �nn�QLuO �/
CaA lei f'_
Parcel Identification No.IPNl
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 CertificatioD jtl�ft t�� a,l't30"
(if well field,one lat/long is sufficient) /� J �• /�• '1
W
N Vt d
Sie�tetun:of d Ccrific Wcll Ctrotrado�
Date:
6.is(are)the well(s) Permanent or [:]Tempnrarc
ey signing this loon,I heretry certify,that the xell(.cl rvCL (x•cre)constrttcred in accordance
Nd,
ith 15A NCAC 02C.0100 or I5A NCAC 02C.02oo Well Construction Standards and that a
7.Is this a repair to an existing well: [3Yes oro copy ofihis record has been provided to the xell owncr.
11'this is a repair.fill out knoxvt well construction information plain the nature of
23.Site diagram or
additional well details'
repair under a21 nmturA,section or on the back of thislarm.
You may 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-
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells SUB1Ni1TTAL INSTRUCTIONS
drilled: r•,
th below land surface: (� (ft-) 24a. For Att Wells: Submit this t'otn within :0 days of completion of well
9.Total well d p construction to the following:
Far multiple wells list aft depths ifdii ferent(ttrarnple-n_i�]00'and-1 ti,100')
10.Static water level below top of casing:40 Division of Water Resources.Information Pro
(ft.) cessing Unit.
1617 Mail Service Center,Raleigh,NC 27699-1617
if tearer tewl tc ahom casing,lice"+
ter 6 1/8 (in.) 23b.For infection Wells: in addition to sending the form to the address f well
t t.Borehole diame
above.also submit one copy of this form within 30 days of completion of well
Air Rotary constntction to the following:
12.Well construction method:
(i.e.auger,rotary.cable,direct push.etc-) Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPL; LLS ONLY: 1636 Alai]Service Center,Raleigh,NC 27699-1636
jr Method of test: Air Ftow 2dc.For R'atrr SunDly&Infection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also subm1I one copy of this form within 30 days of
Chlor Tabs Amount 1 ')2 Lbs completion of well construction to the county health department of the county
13b.Disinfection type: where;consn-actcd.
f Revised,22-'016
North Carolina Department of Emirenmental Qualitv-Division of Water Resu orces
Form GV"-t