GW1-2022-09776_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
r Altai i ii 203!l d
Robert Teague is>:<>: » ..i..
FROM TO DESCRTPTION
Well Contractor Name
(t. fL
B&K Well Drilling Inc rr. ft.
NC Well Contractor Certification Number ... ..........•;..... .. ..........;.;•':'::::`%>':>'%>:
i`•IS�OPS'EBK�CA$7t�TGi for`atntirca9Edsve)"E!OK'1r3r3'rf'i[:": ..•..
2857-A FROM TO DLAMETER TTnCh-AESs NUTERTAL
0 ft. ft, 6118 in. SDR-21 PVC
Company Name
11 1���/} >;1�::13�i9E8aui5SFE��{TR:'E1183!•'iG .;eoCli¢tmakcl..,.., . ::i>a�:•»»;^<'>:«i�>::':»:ri»s,:<?: ::;;:':
2.Well Construction Permit it: `/- 7S/ _`p FROM TO DIAMETER THICKNESS M.ATMA7
List all applicable well construction permits ii.e,l•IIC.Comuv.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
X.
Water Supply Well: - FROM TU DIAMETER SWT$12E THICKNESS MATERIAL
Agricultural Municipal/Public tt ft
in
Gcothcnrtal(ftcating/Cooling Supply) csidcntial Water Supply(single) 1L fL
Industrial/Commercial Residential Water Supply(spar ) :.::•:......•:::>:::;;:;;>::>.:>
. irrigation FROM TO... 1LATERLAL EMPLACEMENT METHOD&AMOUNT
Nun-Water Supply Well: ft. tz
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge E3C;roundwater Remedi4ion ::::::•::....:..:::: •:::.:::::..
r19::SAiY#3LC:RAy'$f>:1!4G�Gf..,,,.::::..}::x�?i:>.`;i<:i::::;:ii:`i:::':?•';:;;:::;:%)ci:::>:;i;_;;:;:x<:::;5?s::
QAquifer Stor2ge and Recovery [DSaliniry Bamer EFROJITO 9LATERLAL EMPLACEMEYf TM;D
flAquifcr Test OStormwatcr Drainage ft.
Experimental Technology Subsidence Control ft.
InGeothermal(Closed Loop) Tracer Geothermal(Heatin Coolin Retum) Other(ex lain under+21 Remarks) k
DESCRIPTION rntor, near soturock' mvtn sac,eta)
tt.4.Date Wells)Completed: 3te11 ID# 1t.75 ft. CA 5a.Well Location:
ft.
Faciiiij/04iner Name Facility 1D�"(ifapplicable) ft. ft.
L l i ft. ft.
3m-
Physical Address,City,and Zip + ' - '•
::'lJi::RF+1�1tXL�11,?'::i:$::::.�).:ij:::�:::::.::i::}�i:::•:.:j: ::�:?}:::•i::::4A�::•:rnx::•{:...::.:::::3r/?::;.:::�:iti�r:.:i:i:::�:i:
�r (Ii I'a:.
County Parcel Mentifiaition No.MN)
5b.Latitude and longitude in degrees/minutrs/seconds or decimal degrees: I
(ifwcli field,one[at/long is sufficient) lnjvivi",a d�1 l�rt> avv- i Urli
N 2/�Certification: iJs C
6.Ls(are)the well(s)oPermanent or OTemporary Sitztaturc of tLnificd W.11 C. acUrr Date
!1-signing this form,I herel,certify that the xrilrsh)vas(xrrc)cautntered in accordance
7.Is this a repair to an existing well- Yes ar with 13A NCAC 02C.01 tie or 15A NCAC 02C.0200 Well Construction Standards and that a
y'this is a repair,ill our Imown well construction informationJndlain the nature oftic copy of this record has been prnvided to the xrll onder.
repair under 921 remarl-s section or on the back,fthis fonn. 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple nr/is lisr all depths ffdii ferent(sample-3`+200'and 2@100') construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
11'.ater level is ahnve caving;use••+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For iniectioo 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 push 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&Iniection 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
where constructed.
Form GW-) North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22=01 o