GW1-2022-07286_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague
FROM TO DESCRIPTION
Well Contractor Name
B&K Well Drilling Inc Uft. 7S rt.
. SQtt.
1 .
NC Well Contractor Certification Number
;�S:.OFI'E`Eit`•CalySlfsiG: ;:::::::::::.:::.:.::;
2857-A FROM 1 TO DIAMETER THICKNESS MATERUII
0 ft-
17 0 ft- 61/6 i m' SDR-21 PVC
Company Name
2.Well Construction Permit#- FROM TO I DIAMETER I THICKNESS MATERIAL
list al(applicablc Nell construction permits fi.e.L11C.Cowtry,State.Variance,ate.) ft. ft m.
3.Well Use(check well use): ft. ft. in.
?i` >::i:.::!;:......
Water Supply Well: FRONINI� TO otAMETER SLOT SIZE THICKNESS MATERIAL
gricultural [3Municipal/Public ft ft. in.
thermal(Hcating/Cooling Supply) [)Residential Water Supply(single) fL fL in.
R idential Water Supply(shared) _.......::.....:......:::::.. ...:: >::::::: ;
Industnal/Commerc.ial es .p y( )
t$:rFiT3T:,>;>s:>::;;;:;;;<:;:;:>:>s><::>:_<;:>:<_; s: s»r:>;:>:->:>i>:>:>:z<»;:>:<:::;>::::>.::
brig tion FROM TO PL4TERML EMPLACEMENT?-=OD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery
Injection Well.
tt. tt.
Aquifer Recharge [3C;roundwater Remedivion
:>:ii:>i%:r::�>::�ii>izs"r.:??;:::>::::3s:�::�iS: :.:
Aquifer Stor9ge and Recovery Salinity Barrier FROM TO 5UTERL4L I EMPLACEMENT PIETHOD
Aquifer Test [3Stomtwatcr Drainage
Experimental Technology Subsidence Control ft. ft.
_....... : .
Geothermal(Closed Loop) Tracer 28:$RTI;Etlt1 .;:1.;N .atmcicadditiouat:3lieets
Geothermal(Heating/Cooling Return) n0ther(explain under#21 Remarks) FROnI To DESCRIPTION color.h2rdndL soiUrock tVe.main she.etc
tt. ft.
r
4.Date Well(s)Completed:7`1271�Well ID# ft. fL
ft. ft.
Sa.Well Location:
fL fL
Facility/Owner Name 1 Facility 1.134(ifapplicable) ft. ft. 7—
C,� e- C. ��U c 1 N� cAkt-\ 4 W 5 4 ft. ft ., 9
Physical Address,City.and Zip ft. ft.
E) nC4t11�a1^. t:..
County Parcel ldentifiaition No.(PiN) .....••fir^� I.JRa 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Certification: _ 7
N W -/ a 'a�)-
6.Ware)the weil(s)ox Permanent or [3Temporary !tarn uro ufCcrtified Well Gmtraut Date
By signing this forest.I herelry certify,that the xr/Ifs)was rxrrc)constructed in accordance
7.Is this a repair to an existing well: nYes or No n ith I SA NC4C 02C.0100 ur 194 NC.IC 02C.0200 Well Construction Standards and that a
!f this is a repair,Tll out known well construction i4onnatin rplain the nature of ire copy of this record hoe been provided to the x-ell onner.
ropair under renua•di section or un the back of thi.,.fonn. • 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 page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ! r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 243. For All Weds: Submit this form within 30 days of completion of well
For multiple nr/fs list all depdcs ifdii ferent tkreunple-3@200'and 2@/001 construction to the following:
10.Static water level below top of casing:40 (n) Division of Water Resources,Information Processing Unit,
wa
/f ter lewl it ahom casing,use••+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Tniection 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 pooh eta)
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 1 &Injection 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 construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourcestl Revised 2-22-2016