GW1-2022-07350_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
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1.Well Contractor Information:
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Robert Teague 14zVYATEi1:Z9iRE t
FROM TO DE.SCRtYTTON
Well Connector Name '/
B&K Well Drilling Inc
NC Well Contractor Certification Number -
;uteliocased?3ve1h
li�iOif'1`ER'GAS7t�G:
2857-A FROM I To DIAMETER THIChzv&ss MATERiAt
0 ft. ft. 61/8! SDR-21 PVC
Company Name G 1 iC
l�� I�::li�iVEKC;I;SIIi(G13R'FU$t!'f�: "':staged- ,,
2.Well Construction Permit#' J FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable Hell construction permits/i.e UIC.Comtry,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well t7::St9tE£Pi» _
PPY FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft. in.
Goothcnnal(HcatingiCooling Supply) RLsidcntial Water Supply(single) IFL {L in.
IndusrnaUCommerctal Residential Water Suppl, (sitar )
irri ation FROM TO rL&TERLAL EMPLACENMNT(61ETHODS.ILMOUNT
Nun-Water Supply Well: ft. ft.
Monitoring ORecovery ft. ft.
injection Well:
Aquifer Recharge [36roundwater Remdia;ion
• :ixli:SAiV#NGRAtiEU:PACKGf'..:.: .. lei:>;:;:<i' >::>:;':>;>''>"::: `»>s:::<>ri:'s <'s:<;:<`%i3::
Aquifer Stor9ge and Recovery [3Saliniry Bather FROM TO NL4,TEIRLAL Eh1PLACEMENT DIETHOD
�Aquifcr Test I]Stonnwarcr Drainage ft. ft.
Geothermal Experimental o Clos dLoop) MTra edence Control ft.
28.�RI#.IIAIGLQ att�haddi
Technology ft.
iinlil sheets:
Geothermal t Heatin Cooling Return) nOther(explain under 421 Remarks) FROM To DESCRIPTION eolpr. Hess m Vrock nm sac,stet
rt. rc.
4.Date Well(s)Completed Well ID#
Sa.Well Location: t _
R. R.
Tc�r l�ro�l�
Facilit11y/Owner Natne Facility IDS(ifapplicable) ft• ft. „� ;E
Physical Address.City,and Zip ft. ft. j 7
„:....:•.
.,'.
Parcel identification Na(PIN)
Ung
County Ut•1�.11
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(lf well fiCld.OOC fdGilOnl IJ O11ffiCtent) 22.Cel-tifi 'on:
N W
J 1
6.ls(are)the well(s)ox Permanent or OTemparary Si eutatutc of 0.rtificd Wcli Contras Detc
Bp signing this(brit.1 hereby cert)(y that the mrWs)was/xrre)consmceted in accordance
7.Is this a repair to an existing well: nYes or Mo uith 15A NCAC 02C.0100 ur hA NCdC 02C.0200 well Construction Standards and that a
!(this is a repair,TIl our known well construction information and .plain the nature o(the copy-of this record has been provided,to the xrll onur-
repair ,under 921 renao-ts section or on the back o(this.(urn. s
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 I GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: __ SUBMITTAL iNSTRUCiIONS
9.Total well depth below land surfacer (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fa-multiple we/Ls list all dcln/ts i(diJ(ereni(etrample-3!_a,200'and 2@1001 CAnStIltGtlon to the following:
10.Static water level below top of casing:40 (fL) Division of Water Resources,Information Processing Unit,
i(warer level La al+nve Caving,ase-+- 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_'4a
Air Rotary above,also submit one copy ofp this form within 30 days of completion of well
12.Well construction method: construction to the following: j
(i.e.auger.rotary,cable,direct push,etc.)
Division of Water Resource's,underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,INC 27699-1636
13a.Vield(gpm) Method of test: Air Flow 24e.For Water Supply&Infection 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 con;ttucrion� to the county health deparmrent of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Rater Re>ources Revised 2.22-2010