GW1-2022-09865_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Robert Teague _..
Well Contractor Name FROM TO DESCRrPTrON
B &K Well Drilling Inc �Xscft-
rt. rc.
NC Well Contractor Certification Number
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2857-A FROM TO DIAMETER TFHCKNESS 11L4rERTAr
Company Name
0 ft. ft 61/8 im SDR-21 PVC
� `•� 165�11�i9EH:�;Stl�1�:F�R?FIIBIPEG:.:. Fhetidal ci : r'::
2.Well Construction Permit#: act ��� � FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable raell construction permits fie,UIC.Counly.State.Varita cece,ate.) ft m.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 7 .. _.....: _.,... . . .,.:.... :.. ...:...:..::.,....._>::�:..,.:. :,.:::,,.::..•::::::::.::::
FROM TO I DIAMETER SLOT CIZE THICKNESS MATERIAL
Agricultural [3MunicipaLTublic ft ft. in.
:,)Geothermal(Heating/Cooling Supply) gidcn[ial Water Supply(single) ft ft in.
:]Industrial/Commercial
esidential Water Supply(shared)
:z:18s:Gut 013`f?E`•
it'rigation FROM ...:TO :^:r.LILTERLAL EMPLACEMENT METHOD&•AMODNT:
Nun-Water Supply Well: ft, rc-
Monitoring DRecovery
Injection Well:
rt rt.
_. Aquifer Recharge nciroundwater Remedivion
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PAquifer Storage and Recovery [3Saliniry Barrier FROM TO I EMPLACEMENT METHOD
r3Aquifcr Test [3Stormwacer Drainage ft. ft.
nExperimeatal Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) [3�Tracer
Geothermal(Heating/Cooling Return) MOtlier(eV lain under e21 Remarks) FROM To DESCRIPTION color.bxrdnss soiurocl Drain sim ctc.)
e. ft. i G
4.Date Well(s)Completed: 2,Z Well ID# fur ft.-
5a.Well Location: y ft. R.
—o.. ..
Facility/Owner Name kciliEy 113R(ifapplicable) ft. ft Z n Igti7..
172 GL �5l.'—h�s 1 L)� I?L1 ft. ft. R
n
Physical Address,City.and Zip ft. ft. 20
Z.
3
t>> rco-
r� 1 :t 1 �'
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lonc is sufficient) 22.Certift tion-
N W X3
6.is(are)the well(s) x Permanent or Temporary Signature ofCcnified Vfell Contmator Date
By signing this form,7 herelry certi)5?that the xrllfs)ivat(wore)consaucted in accordance
7.is this a repair to an existing vvell- DYes OeONo with 1.5A NC•tC 02C.0100 or 1M NC:1C 02C.0200 well Construction Standards and that a
!/'this is a repair,•1711 ora known well construction infonnatio"rt an explain the nature ofihe copy'ofthis record has been provided to the well owner.
repair unds,R21 remarks section or on the hark of this;/ono.
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 G�1W-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: '1 )/n� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / U (fi) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells lisr all depths 7fdiierent(arainple-3`200'and 2@/00) construction to the following:
10.Static water level below top of casing:41) (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is ahnve casing,rose"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For infection 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 push,arc.) -
Division of Water Resources,underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 !
1
13a.Yield(gpm) Air Flow 24c-For Water Su alv&Injection Wells: In addition to sending the form to
t7� Method of test: P o
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ChIOfTabS Amount-_ 112 Lbs completion of well construction to the county health department of the county
where constucccd.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 +
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