GW1-2022-07400_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Robert Teague a x. Alltzoiv
FROM TO DE.SCRIMON
Well Contractor Name ft !t
B&K Well Drilling Inc
NC Well Contractor Certification Number
1SiOUTER. G: utaiircased:ael .DLtL11VP1 if''"
2857-A FROM To DIAMETER Tfncx�vFss M+rEtunL
p ft. I 6 C-ft- 61/8 m- SDR-21 PVC
J✓
Company Namc `l
^� L / 1&liG1VB1LiS11tGflRtilBtDjG t�ermaketosed-Io
2.Well Construction Permit# ��— C3 `�I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable x-ell construction permits li.e.UIC.Comity,State.Variance,ere.) ft. ft in.
!L (L in.
3.Well Use(check well use):
Water SPPYn I Well:
FROM i TU DIAMETER SWTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft. in.
:.)Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) ft fa in.
,.._......
IndustnaUCommercral esldeaual Water Supply(st tared)
.. . ....:lrri anion FROM To PtATERTAL EbtpLACEMENTDtETHOD&.1MOVNT
Nun-Water Supply Well: rt. ft
Monitoring ORecovery
injection Well:
Aquifer Recharge [3Groundwater RemediVion
13 Aquifer Stor2ge and Recovery [3Saliniry Bather FROM I TO EMPLACEMENT DIEfHOD
�AquifcrTest oStormwatcrDrainagc ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 2&::BItTI.F1t1G1 'aftachadd#ioksbeets- J:
FROFI TO DESCRIPTION color, rdna~,soiVroekeevmsia,ete.l
Geothermal(Heating/Coolin Return) Other(es lain under 421 Remarks) ft ft. LK
1 1 ii
4.Date Well(s)Completed Well ID# ft' e L
VA I
ft. rt.
5s.Well Location: —
SCA liAce� t
7\ ft
ft. ft.
Facility/owner Name Facility LW"
D"
S`T 4 s v 1 �-G v, 17{�, ft. rt.
Physical Address.City.and Zip L t
—•/'-t" ;..... ... :..,
County Parcel identification No.IPTN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Urvilt
(if well field,one lat/long is sufficient) 22.Certin •on:
D�,,J M.00
Datu
6.Is(are)the well(s)OPermanent or OTemporary SlLmalutc of Ccnifrcd well aaca,r
by signing this fibrin,I hereby cert?f that the xrWv)was txcrc)commtcted in accordance
7.1s this a repair to an existing well: Dyes or [ No frith 1 SA.ti'CAC 02C.0100 or!JA NCAC 02C.0200 well Construction Standards and that a
!('this is a repair,ill oil'known well canstruction information aA e*plain the nature of tint cop} /this record has been pro v del to the xell owner.
repair tinder 921 remarks se rion or on the back of thisfionr.. 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 attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth ow land surface: "IA (ft-) 242. For All Wends: Submit'this form within 30 days of completion of well
For awltiple x'ells list all depths ifd/(rerent(trample-3r,_00 and 1@100� constntcdon to the followin^:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
If tearer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) lib.For Infection Wells: In!addition to sending the form to the address in 34a
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 paslL 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&Injection%yells: In addition to sending the form to
the addresses) above, also subinit one copy of this form within 30 days of
13b.Disinfection type: Chlor Tabs Amount: 1 112 Lbs completion of well con;trucri fora to the county health department of the county
I
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised'--22-_'016