GW1-2022-07358_Well Construction - GW1_20220808

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague I4> tATE>1zoi
FROM TO DE,SCRIF I WN
Well Contractor Name O ft.
B&K Well Drilling Inc LD rt fc
NC Well Contractor Certification Number atattrcased:3ve1 t1Riilt
Z8S7-A FROM TO DIAMETER THICKNESS hLaTERIAL
0 ft. tt. 61/6 : in. SDR-21 PVC
Company q��q
tP Y Name 16Iii13VERLi)iSINC>{TR'fU$t19G tiCBeztYtattiuee8-too : ;
Lib FROM TO
2.Well Construction Permit# DIAMETER THICKNESS MATERIAL
ft. In
List all applicable well cor6trucaon permits li.e.UIC.Counev.State.Variance,etc.)
ft.
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM To DIAaI LTER SWT 512E THICKNESS MATERIAL
Agricultural E)Municipal/Public it.
Geothermal(HcatinglCooling Supply) Residential Water Supply(singlo) k fL in•
lndustnaUConnuerLlal esldanual Water SuPP1Y(Shared)
)
' FRU1.7 TO DL&TEItIAL EMPLACEMENT DIETHOD&AMOCINT
lrri ation
ft. ft.
Nun-Water Supply Well:
Monitoring ORecovery ft. ft.
injection Well: ft. ft.
:)Aquifer Recharge [3Grounwater d Remediaition
:SAiv#NGItAkl•;f;:P.ACiF tkabk
Aquifer Stor9ge and Recovery Salinity Barrier FROM TO AL9TERLAL EMPLACEMENT DIECHOD
r3Aquifcr Test [3Stormwatcr Drainage ft. ft.
Experimental Technology Subsidence Control ft.
Geothermal(Closed Loop) Tracer :AVAT1.i.I O r.aysehadditiuiiaEsheelsif_'
FROM To DESCRIPTION eotor. nevi-01—l: to sae.eta)
Geothermal(Heating/CoolingReturn) Other(ex lain under P21 Remarks) ft.
ft.
3�a ft. rc. tJC=
4.Date Well(s)Completed Well ID#
ft. ft.
59.Well Location:
Facility IDd(ifa liable) ft. ft.
Facility/Owner Nantz Y PP
ft.
9� UDC
ft. ft.
physical Address.City,and Zip
21
County Parcel identification No.(PIN) Iti�t
�OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �2Cer'
N W
SitlraturcofCcrtifi WcllCnntracWr Dater
6.ls(are)the well(s)oPermanent or E]Temporary
By signing this form.I herelry certify,that the xrllts)was(were)consrn¢red in accordance
7.Is this a repair to an existing well: DYes or No uith l.5A NCAC 02C.O100 err l5A NCAC 02C.0200 Welt Construction Standards trod that a
If this is a repair,ill out brown well eonsiractiott information and .Tplain the nature ofdte copy of this record has been prnvidcd to the well owner.
repair under 921 remarks section ur on the hark of this form. r 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-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages ifnecessary.
drilled: 2 SUBMITTAL INSTRUCTIONS
9,Total well depth below Land surface: ✓ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nru/tip/e err//s list a/l depths ifdiJfetrn[(cranple-3!0 QUO'an ?@/001 construction to the.following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
tl'%vater level is above 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 puslL etc.)
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 A 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: 1 112 Lbs completion of well construction to the county health department of the county
what:constructed.
Form GV.'-1
North Carolina Department ofEnvironmentat Quality-Division of Water Resources Revised 2-22-2016