GW1-2022-09820_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
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Robert Teague aoxl; :;;<:>;.>:<:<.<>::>::<::>::;::>:.:;:::<�>:>;><::::::::::<><><>._.:>:::::::�:<:�::>� ;:;::>::;:::�>::><::.;:>
FROM TO DESCRIPTION
Well Contractor Name
70
B &K Well Drilling Inc
NC Well Contractor Certification Number :. ..... ....:. ..:.::.�: :::.:::.;:.:...... .... .:.,...:-_.:.:::_.,.:;.....
<t35S Gii511`IG' .:rgnth-cased;svxtts iDlZ�ifQLtfi.i[;.�.:,� isi<'u?:>?:s<
2857-A FROM To I DLIMETER THICKNESS I MATERIAL
a ft. ! ft. 61/8 �' SDR-21 PVC
Company Name 1
l >�.:�1�ER���-� ealf.ro .:..: ........ ........ .::
2.Well Construction Permit# FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicablexell constmcdon permits(te.UIC.eDwnty.Stare.Variance,etc.) ft. ft. in.
3.Well Use(ebeck well use): ft. ft in.
Water Supply Well: FROM I To DIAMETER SLOT SIZE THICKNESS` MATERIAL
Agricultural r3Municipa/Public ft ft. In.
Gcothermal(Hcating/Cooling Supply) Rtaidential Water Supply(single)
shared
e c�a esidential Water Supply ) ;>:�i:�><:>;;?�>:�>:�:>�'�`����>3>::%�»:.,...
IndustriaUComnl r t 1 PP Y( ' '
lrriaation FROM TO DLATERLAL EhfPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft_ ft.
Monitoring 13Rccovery ft. it.
Injection Well.
Aquifer Recharge In Groundwater Remediationz<,><ai:< ; :;.
z't�9iihltl#1TGIkELACfCajF e :..::...:..:...:...:.:....:....:....:.......-......._._............
Aquifer Stor9ge and Recovery Salinity Barrier FROM TO ALATERLAL EMPLACEME`tT METHOD
Aquifer Tcst [3Stormwatcr Drainage it. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 2h::AIiT1iEIl!iGLOO. ttacfiraddtttoira#.sets "''
FROM TO DESCRIPTION color,hardn oltfroel. rn size•etc)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) tt. tt. r-
4.Date Well(s)Completed.-OL Well ID# tt. ft. C-t Y L1
5a.Well Location: ft ft. 7 /
ft. 1 ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) �.
n 1 A Ca-P-V man 2 1 ft. ft. i x
Phys"cal Address,City,and Zip
r:
' :'�'R.R31F6RK?C::x•..:::;::: .,,,,:..:;<.:<.,.:
County Parcel identification No.(?IN) 1 •O f B t^,l t't.^. Saui: nu
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Rl -
(if well field,one[at/long is sufficient) 22.Certify. 'on:
N W C6
6.is(are)the well(s)o%Permanent or [3Temporary Siptdturu of Certified Well Gm detor Datc
ky signing this form,I hereby certify that the x-ellts)was(wcre)consinated in accordance
7.is this a repair to an existing well: Yes or o with LfA NCdC 02C.0l00 or ISA NCRC 02C.0200 Well Construction Sumdnrds rrnd that n
If this is a repair,fill out known well construction information and tx lain the nature o(the copy olthis record has been provided to the xrll owner.
repair under#21 remarks section or on the back of this fann. 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 if necessary.
drilled: (� SUBMITTAL INSTRUCTIONS
9.Total well depth Blow land surface: t•O (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
Fnr nwltiple wells list all depths ifdlffereni(erainple-3@ 200•and 2Q1001 construction.to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,information Processing Unit,
If water level is above.casing,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
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,rolary,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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-2-1-2016