GW1-2022-07354_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert TeagueTim
FROM TO DESCRIPTION
Well Contractor Name
B &K Well Drilling Inc q5 ft. /5 ft.
NC Well Contractor Certification Number
3:[:01$1`E$:l�AS71!iGi uiflite?cilseilivel :ET1L'ai3b?il'r[`
2857-A FROM I TO DLAWTER TMCkNFSS KATERTAL
D ft. G ft. S 7B ! m SDR-21 PVC
Company Natnc
a C1 Ll FROMNEli: c olt�t4stclM malr:�l ICK
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well ca fi utntcuon permus -e UIC.Comm+.State.Variance,etc.) fL fL ! in.
fL ft• in.
3.Well Use(check well use):
1:7::Sc3tEEty `.
Water Supply Well: FROnI TU DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public rt ft. in.
Geothermal(icatingiCooling Supply) R
Residential Water Supply(single) ft in.
Industrial/Commercial Rrxtdenual Water Supply(Shared) 4.
i8: t�OF3'i....:.
Irrigation FROM TO \LATERLAL EM1tpLACEMFIr7ICIETHOD&AMOUNT
Nun-Water Supply Well: ft. ft.
Monitoring ORecovery
injection Well:
Aquifer Recharge [3Groundwater RemediVion
1:}:i�AN#iIC'ICTy�L':�!AGK'Gf:��:::
Aquifer Stor2ge and Recovery Salinity Barrier FROdt TO NUTERUL EMPLACEKLNT METHOD
Aquifer Tcst [3Stormwatcr Drainage ft• ft.
9 Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 28s9RSi:Eil'1GL0;•attacli:sdditiontt}aheets:i[:
FROM TO DESCRIPTION color,t a dnms"WraeA —in sae,etc.)
Cieothemial(Heating/Cooling Return) Other(explain under#21 Remarks) ft L fL
t'
4.Date Well(s)Completed —6 well ID#
ft
' Sa.Well Location:
W �� ` \ )f1 C) G fL
S fL .
Facility/Owner Name Facility IDS(if applicable), 8. LULL
ft.
Physical Address,City,and Zip
�Q��. 2I:REi1iAIt1S�:»:i::_::;:;:y::;:::';:.:;`:;<:?:;•.;;.::;• '%tz:Yy: s
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.CerZ�z
N
Si,atatun:of Certificd W- Contractor Date
6.ls(are)the well(s)OPermanent or Temporary
By signing this form,I herelry certify that the xrllrs)wac(urre)constructed in accordance
7.Is this a repair to an existing well: [)Yes or-ONo t,ith 15A tiC4C 01C.0100 ur 15A 1VC.$C 02C.0200 Well Construction Siandards mul than a
if this is a repair,ill out brown well construction infonnation an explain the nature of the copy'of this rcnrd has been provided in the xr(1 order.
repair under 921 remarks section ur un the hark of this form. 23.Site diagram or additional well details:
S.For Geo robe/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 attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (It-) 249. For All Weds: Submit this form within 30 days of completion of well
For multiple urlk liv all drpths ifdii frrrnt(:trmnple-3!_200•and CW l00J construction to the.following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If rarer level is al ove.casing,uw'•+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (I^•) 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 of well
12.Well construction method: constntction to the following:
(i.e.auger,rotary.cable.direct posit.etc.l i
Division of Water Resources,lUnderground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
132.Vield(gpm) Method of test' Air Flow 24c.For Water Suploly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs 1 112 Lbs completion of well ronstrucrion to the county health depw=ent of the county
13b.Disinfection type: Amount: P ,
where consnuctcd. a
Revised?•??-2016
Form C K'-1
North Carolina Department of Environmental Quality-Division of Water Resources