GW1-2022-07299_Well Construction - GW1_20220809

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague
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FROM TO DESCRIPTTON
Well Contractor Name
B &K Well Drilling s ft. 5� d a
9 Inc
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NC Well Contmctor Certification Numbe 1Si:0UTEIt:CAS1PTG€ec iiiakr ca ieii tvelts ORLIVEA;[s 'l`
2857-A FROM TO DIAMETER THTCiC--ESS MATERIAL
`\ 0 ft-
t ft- 0 18 SDR 21 PVC
Company Name
"I6:>11v1VSRG)tSfl`FC OI'Ell$t!'IG:`" at:closed ioo ::
2.Well Construction Permit#: l 3t7� U�S FROMTO DIAMETER THICKNESS MATE IAL
List all applicable well construction permits 6.e.UIC.C:owny.State.Variance,eta.) fL ' I. in.
3.Well Use(check well use): fL ft. in.
.....: ..
i7t:SC�iEEIY
Water Supply Well: FROM TO I DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural E)Municipa/Public rt I f. in.
Gcothei-mal(Ticating/Cooling Supply) VResidcntial Water Supply(single) ft fL I in.
IndustrlaLCornnterLtal Residential Water Supply(shared)
lrri Lion FROM TO MATERIAL EbnPLACENIFdvT METHOD&AMOTNr
Nun-Water Supply Well: tt. fL
Monitoring ORecovery ft- ft.
injection Well: tr. ft.
Aquifer Recharge [3Groundwater Remediation
• 19::SAiVflICIt�y1';L Gf lt�le} .
Aquifer Stor9ge and Recovery [3Sa1iniry Barrier FROM TO .)L4LTERLAL EMPLACEMENT METHOD
Aquifer Test [3Stormwatcr DrainaLc ft. ft.
Experimental Technology Subsidence Control tt. ft.
Geothermal(Closed Loop) Tracer 28 faltII EIg1Gi 0 :aittieltaddrnoiiilslteem T
FROM TO DESCRIPTION rnlor.hard aS."Wrock min size.etc-)
Geothermal(Heatir*Cooling Return) Other(explain under T21 Remarks) ft rt
t
4.Date Well(s)Completed:? t — well ID# ft. R. G`lr
art. L Yt. r >✓
So.Well Location:
ft. ft.
r r avu_ �i')l�5�f U bV�
Facility/Owner Name F alit 1D#(ifappli+cablte)) ft. ft
rr
ft. ft.
Physical Address.City.and Zip
23 REiK4R1{S ,
County Parcel identification No.IPiN) n I J4 ;... v,n. n
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one IWIong is sufficient) 22.Ce�a
N W 7 S
6.!;(are)the welt(s)OPermanemt or Temporary ignatun,of Ccrtificd WeContractor., Datc
BV signing this form.I hercly ccrtiti'that the vrllSs)was(xrrc)consmicicd in accordance
7.Is this a repair to an existing well: E)Yes or No !,'ith l-5A NC.4C 01C.O10O ur!S.9.NC:4C OIC.0100 well Cunstrucriun Strundnrds and drat a
f/'this is a repair,llll ors known well canstnation infortnation dud Nplain the nature ofthe coo-of this record has beer,prnv'ded to the xrii Darner.
repair under 911 rtnua•6-s section or on the bark of this funn. 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 details. You may also artach additional pages ifnecessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well dept below land surface: ` IJ C (ft-) 242. For All Weis: Submit this form within 30 days of completion of well
For multiple well.;1Csr all depths ifdi ferent(xatnple-3gx200'and 2CR100� construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
q';vater level a above caving,tag +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) lib.For injection 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:
ti.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
132-Yield(gpm) 3 Method of test: Air Flow 24c,For Water Supply&Iniec$on 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: t 1/2 Les completion of well construction to the county health department of the county
where construct W. K
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-:016