GW1-2022-09867_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague R .:�.:;.:::.>::.:;.:<>�::;:>;<;;:::«�::::>:::ai»::<::;:::;:::>:>:>i>::>
Well Contractor Name FROM TO DESCRIPTTON
B &K Well Drilling Inc S CJt• G ft. �.
ft. ft.
NC Well Contractor Certification Number
::SSOF£FEiYG7NG` _uiaiFessediri4&'ES$ f "i> 'z't<z ;y; :;;p;
2857-A FROM TO DLIAIER 1 THICKNESS ALATERIAL
. 0 ft.
TE
C) ft' 61/8 in-- SDR-21 PVC
Company Name l.J
Q �f �/ Il1BfS]FIG.flR7U$TkIC eetaidsmabtlasMe =
2.Well Construction Permit#:�w tsVq,(�p/ -(/ /7 j� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable tell eonsnttedon parmus(Ld-U1C.County.Stare.Variance,etc..) R. ft. t°'
3.Well Use(check well use): ft. ft. in.
Water Supply Well: �..k.SQ;. ._...
PPY FROM TU DIAMETER SWTCIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public ft ft. in.
Geothcrmal(Hcating/Cooling Supply) OResidcridal Water Supply(single) ft ft. in.
tial Water Supply ::•:>-.:;•:;:.:;.»:•;:_>:::.;>:;.;>:>:-;:-:<-;>;::•::•::;:• : : .:;; <:.:•;::> »;•:::x;: :;:
IndustnaUCommerc Ial eslden r PPY I ::CtF113T ::::.,.:::
irrigation FROM TO ALATT12L1L EMPLACEMENTr ETHOD&AMOUNT
Non-Water Supply Well: ft_ ft.
Monitoring DRecovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge EICroundwater Remediation -
<:19it>iV#?1i�Avt PAG3.{f:.,,.:,-:::::V <;:;<:::>:;';:;>;;:»: : p:>:::>;:<:;
Aquifer Stor9ge and Recovery E)Salinity Barrier FROM To ALATERLA.L EMPLACEMENT METHOD
AquifcrTest DStormwatcrDrainage . ft. ft.
Experimental Technology E)SubsidenceControl ft. ft.
Geothermal(Closed Loop) Tracer ::i2i#:: fiPl :I17i . ttachasTrhL aE>:«;::.=;::<::: :<<<%,> s3``
Geothermal(Heating/Cooling Return) nOther(explain under 921 Remarks) FROM To DESCRIPTION mlor.ha ess,30111 ek in size,etc)
20 it. tt.
4.Date Well(s)CompletaR- -a-3-')L `Well ID# ft ft- hard. -1 c ci:N J CJ
it. tt.
5a.Well Location:
YZ��y )Azft. ft. L=•r
1 --
Facility/Owner Near- Facility 1D#(if applicable) ft. ft.
t V ft. ft. 9
rt. ft.
Physical Address,City,and Zip
. :: R€aclrhRiiC:':......::::...::1;::•;�.:::+:.�;:;.g-:,;y,;;:.:;�:.. w...._.x�:k:;o.. :,> .
County Parcel identification No.(?IN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certificatinn-
N W -
6.Is(are)the well(s)OPermanent or OTemporary SigmaturoofCerrified We I—Factor Date
r-t 8v signing this font,1 hereby certify that rho xellis)sva,(acre)consinicted in accordance
7.is this a repair to an existing well: 3Yes or LING ith 15ANCAC01C.0100 or 15ANCAC 02C.0200 Well Construction Standards'and that a
If'thls is a repair,ft11 out known well construction information an lain the nature of the copy ofthis•record has been provided to the xrll owner.
repair under#21 remark section or on tire back of this(orm. 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
5:
9.Total well depth below Land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
9.Total well dep-thkek w land surface:
For otultiple wells ILsI all depths if&fferent(e-ratnple-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing:40 (ft) Division of Water Resources,Information Processing Unit,
jlvater level is above casing,use-+" 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,etc.)
j Division of Water Resources,Underground injection Control Program,
FOR W ITER 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
i the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type:
Chlor Tabs Amount: P 1 1/2 Lbs . completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality•Division of Water Resources ' Revised 2-22-2010