GW1-2022-05711_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague IIAi�R:20N1✓S r. ;..;
Well Contractor Name FROM TO DESCRIPTION
B&K Well Drilling Inc I
NC Well Contractor Certification Number :QtY i E[LGt137NG �ettl cs.....e f iit331!t#s R'it
2857-A FROM To DIAMETER TffiCKNESS MATERIAL
0 ft. ft. 6118 in. SDR-21 PVC
Company Namc l ��
1b3N1VElt` E)R FU$1YG' eet�etmazld�tob ;'.
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.Comity,State.Variance,etc.) ft. D ft f t 1 1 r"' L,
3.Well Use(check well use): tL. tt. in.
Water Supply Well: FROM TU DIAMETER SWT cIZE THICKNESS MATERIAL
Agricultural OMwticipaJPublic ft ft. in.
r-IGeotheiina](Hcating/CoolingSUpply) aRcsidcn[ial Water Supply(single) ft ft to
industrial/Commercial Dkesidential Water Supply(shared) FS.f RQIIT
irrigation FROM TO MLITERLIL EMPLACEMENT NIETHOD&AMOUNT
Non-Water Supply Well: ft. fc
Monitoring ORecov'ery
injection Well:
Aquifer Recharge OCiroundwater Remediation
L9:S[1V#lJG1tAYEt#'4C liceble
(Aquifer Storage and Recovery [3Salinity Barrier FROM TO NLITERL4L EMPLACEMENT METHOD
Aquifer Tcst [3Stormwarcr Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 2TfitIIEIIsY1)C:attach.adcGteiel3ltts '
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks] Fit
To DESCRIPTION rnlor,ha ss soiVrock n grain size.etc.)
4.Date Well(s)Completed-_"-_) �a Well ID# 3 ft. O ft. (�,r
5a.Will Location:
N K ft. ft.
Facility(OwnerName ,p Facility lDlt(ifapplicable) fr. ft.
ft. ft.
Physical Address,City,and Zip
GL i`.'
� � v,rm� t fit:'
County Parcel identification No.(PIN) DkVQ/B0G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W �
6.ls(are)the well(s)oFermanent or OTemporary Signature of Cenificd Wcll Contra r Datc
By signing this form,I herelry certify,that the xr/I(.$)was(were)consrnrcred in accordance
7.Is this a repair to an existing well: OYes or No a ith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
Ifthis is a repair,fill out knoxm well constriction infonnationA.nd 'plain the native ofihe copy of this record has been provided to the"ll owner.
repair undo-921 remarks section or on the bark of this fonn' 23.Site diagram or additional well details-
b.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 (ft-) 24s. For All Wells: Submit this form within 30 days of comple6ou of well .
For multiple ur/1s list all depths if rent(trarnple-3!Zc.200'and 2 a 100') construction t0 the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,ace"+" 1617 Mail Service;,Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$ (in-) 24b.For Iniection 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 01"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
13a.Yield(gpm) Method of test: Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs completion of well constructiouf to the county'health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Rater Reso rc leg Revised'_'-22-_'016