GW1-2022-07353_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD (GA-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague L>>graT: oiv>w
FROM TO DE,SCRTFTION
Well Contractor Name �g• ft. V
B &K Well Drilling Inc art. rt.
NC Weli Contractor Certification Number
I�OEi'6ER�Ci1�11vG.taritialtrcased>srells:E3Iti.31V�;EL ii'
2857-A FROM TR DIAMETER THICKNESS MLATERIAL
0 ft. I ft. 6;/8 in. SOR-21 PVC
Company Namc �+ /1 Ib;1NN81ZGf51Ft641tFU$1CtG r1
2.Well Construction Permit#: f�J fp FROM TO DIAMETER THICKNESS MATERIAL
ft.
Liss all applicable w.e17 corrsrnection permits fi.e.U1C.counn+.Stale.Variance,ete.)
ft. In.
ft. f[, in.
3.Well Use(check well use):
1.7.SC3tE£h'
Water Supply Well: FROM TO 0IA1%1 EfER SLOT SIZE THICKNESS I MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(HcatingiCooling Supply) Rcsidcrttial Water Supply(single) ft ft.
..)Industrial/Commercial Pp�� estdenual Water Supply(shared)
IDdustnaUCom L.�
. FROM TU NuLTERLI L EhLPLACEMENT METHOD&:AMOUNT
Irrigation
Non-Water Supply Well: ft. ft
Monitoring r3Rccovery
Injection Well: ft. ft.
Aquifer Recharge [3Groundwater Remedi4ion
:13::SAiY#INtr11AVE iOAMCK'{.tf�.....:1lfelik} ;%:i; :G"' 3`i i :i':�ii<;:?T MET ':HOD.
Aquifer Aquifer Stor#ge and Recovery Salinity Barrier FROMTO ML4TERLAL EMPLACEIvtL MIETHOD
�Aquifcr Test [3Stormwatcr Drainage ft• ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) 13Tracer Y&BR73 E3PIGLQ >,ttael�DEsCRIPTIONJe Ii£ueeess
FKOSI T OESCK1PT1pN trobr.hardness.wrUtroek mein sac ctal
Geothermal(Heatin Cooline Return) Other(explain under t21 Remarks) tt. ft.
4.Date Well(s)Completed Well ID# S ft. R.
5a.Well Location:
t ft. Y
W X ti)l G.inU 1\J C1\`1 oc Vol i✓r t
acilit tDm(ifa applicable) ft. ft.
Facility/Owner Nattte Y PP '
��b�► \mil cA Vol B Tr- S h�►'1' ► 1�S r0�d ft. ft.
it. it. �-,-� •
Physical Address.City.and Zip
� ,�1 SI RE1liskitl{S
County
w Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio -. 1.1 j>,gQ1zoG �7
N W
5_•natun:ufCcrti6cdWcllGm •tor. Date
6.Is(are)the well(s)ox Permanent or Temporary
By signing th&form.I hereby certify that the xr1la)was(weer)consrnrcted in accordance
7.Is this a repair to an existing well: E)Yes or No vith 1 SA NCAC 02C.0100 or ISR,NC.4C 02C.0200 well Consrrucdun Standards and that a
if thh%is a repair,i'll ota know"well construction infannadon on splain the nature of the ropy'of lhis record has been provided to the xrll ou"e%.
repair under 9:1 renurrks section ur un the bark of this funn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.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-I is needed. Indicate TOTAL NUMBER ofwelis
drilled: n� SUBMITTAL INSTRUCTIONS
9.Total well depth WoO land surface: 49 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all delydu if rent(lxarnple-3('200'and 2CR 001 construction to the followin^:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
ft'rsater level is al+ove arcing,tcse-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
17.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 push etc.)
Division of Water Resources,i Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
s I
13a.Yield(gpm) Method of test Air Flow 24c-For Water Supply&Tniet titin 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 1l2 Lbs completion of well construction to'the county health department of the county
where constructed.
1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resourc Revised 2-22=016
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