GW1-2022-09780_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L.Well Contractor Information:
Robert Teague
x.
Well Contractor Name FROM TO DESCRIPTION
B &K Well Drilling Inc fL
fr.NC Well Contractor Certification Number ft.
33tifdllEEi2iA�71YGi...: ffirasedi,.;. ':�33F ..;,::.:.:,,.,.•.::". i':•' ?' `.'>%i;S
2857-A FROM TO DIAMETER TEIECKNESS MATERIAL
Company Namc p ft. ft 6 118 in. SDR-21 PVC
?iZG 1 1�TEftF#SI11fCxE)ATIISDFG: eetrieitaabcl ldoe' a .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permus(ia UIC•Cbu nry.State.Variance,etc) ft. ft. in.
3.Well Use(check well use): tc. ft. in.
er Supply W ell. �:7 5t3fEF3t»:;;:»>::.:<.:•;�.:::::::::.�:..,� -
FROM
R TU DIAIIIETER NWT CIZE Agricultural C]MtmicipallPublie ft tc. in. THICKNEs$ MATERIAL
GeothcnTtal(Rcating/Cooling Supply) WResidendal Water Supply(single)
I ft ft in.
Industrial/Commercial
ommercial Lesidendal Water Supply(shared) •.:.:..... .........:,...:.:.:.:,:.::•::::.:.._;.:-::..::::::::::•::.::::•:::..::.:.:.:...::::.....::::::.:::.�::.:;::,:;•>.�t&:i�R(Tb3?:::;::::;:::::::i:�:;:s;:=Isis::::!:::;;?s8�<:;:;:>::Y:�!:::::;<:::::.:<•;::x::::;5:.::;:.:c<:::a:•;:�;:.;.::::::::::::.�:..
Irrigation FROM TO KATERLU EMPLACEMENT METHOD&:1MODNT
Nun-Water Supply Well: ft. fL
Monitoring DReeocery ft. fL
injection Well:
F—lAquifer Recharge rlGroundwater Remediation R. ft.
A n fen Storage and Recovery ry �San.ryBaer 1�:`$iYiYdll�sl2'.9ik" E'ti!4F ' f:: .::.::...;:iii;::%:i?ii:%;;;i>;!::.:.;.?.s.:;..:.:..:.%...::.?:?.i.;...'...`.:z...a..i.i.2.>::::;:::•;:::;::.;,::r:.:...:
FROM TO PLATERL4r. EMPLACE.MEYTQtETHOD
r'lnAquifcr Tcst [3Stormwaccr Drainage ft. fr.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
�?8Ii1�f1N+G-1jE)C'aUacka&iGiee�".<.;�.: .. .;,..::.:;:,:'':' '•:'•>•fz::'? .............
Geothermal(Heating/Cooling Return) rlOther(ex lain under R21 Remarks) FROM TO DESCRIPTION color.hardn soIII k tc °nano sla.act
ft. ft.
4.Date Well(s)Completed: V ) 277-- Well ID# ft. ft.
52.Well Lo �
ea n: 5 tt. S ft.
Facility/OwnerNamz /p��� p FaciliiylDd ifapplicable) t• ft.
3 CJI� f •..a-
ft. fr.
Physical Address,City,and Zip ft. ft
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County T— Parcel ldentificationNo.(?TN) A •.n 7r,�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
N W
Z.
6.Is(are)the well(s)OPermanent or Temporary Si- aturu ofCL-nificd Well Contractor Date'
By signing this form.I herekv certify chat the xa/!(s)wac lw•ere)construcred in accordance
7.Is this a repair to an existing well- []Yes or IgNo with 1 iA NCAC 02C.0100 ur!SR NCAC 02C.0200 Well Construction Sutndards and than u
lfthis is a repair,all our known well cansnuuion information Cod&plain the nature gfdre coV1'gfrhis record has been provided to the wall oicrur.
r•apair under-921 renua 4s secdon or on the back of this,fornn.
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft 24a. For All Wells: Submit this form within 30 days of completion of well .
Far multiple wells list all depths)fdifferent(arm
construction to the following:
10.Static water level below top of casing:40
(ft.) Division of Water Resources,Information Processing Unit,
1/'water level is above caving ace'+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push etc.)
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
73a.Yield(gpm) ` Method of test:Air Flow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlor Tabs 1 1/2 Lbs the addresses) a�ove, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GWW-1 North Carolina Department of Environmental Quality-Division ofWater Resources Revised 2-?'-2016