GW1-2023-01920_Well Construction - GW1_20230222

WELL CONSTRUCTION opt-niDr%f., :Z
jrW_1) For Internal Use Only:L Well Contractor information:
Robert Teague
Well Contractor Name
FROM TO - XIFTION
2857-A �q_. (i ft.
NC Well Contractor Certification Number ft. ft.
B &K Well Drilling Inc UMMTE (&F.—
se Ekfirii-p-1 6,
FROM
TO DIAMETER
Company Name 0 ft. ? . THICKNESS MATERIAL
61/8 SDR-21 PVC
2.Well Construction Permit#: N3,0R. 'q11rrrj­'­­
.closed
List all applicable well construction permits(i.e.UIC,cole(a FROM TO DIAMETER THICK
NESS MATERIAL
in.
I WV Use(check well use):
ft. ft. in.
Qt
Agricultural M
TO
DMunicipal/Public DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.
Geothermal(Heating/Cooling Supply) j§ResidentiaI Water Supply(single) ft. ft.
Industrial/Commercial 13Residential Water Supply(shared)
inl
Ini ation
Non-Water Supply FROM TO
Well; A]
Monitoring ft. .RIAL EMPLACEMENT METHOD&AMOUNT
Injection Recovery ft. . ft. .....
Aquifer Recharge ft. ft
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Monitoring
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othermal
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Supply
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Aquifer
r e
q f e Recharge
DGroundwater Remediation
g
Aquifer Storage and Recovery 08alinity Barrier RAVE
alla PlIcable
f r T I
FROM
Aquifer Test TO
Experimental I - E2Stormwater Drainage ft. ft. MATERIAL EMPLACbMILN r METHOD
Technology
.
e h Technology OSubsidence Control ft.
emn
Geothermal(Closed Loop)
Geothermal
rm I(Heatn Tracer z
G O.;;,]D
eothermal(Heatingf('rinji—P.h.—)
Other(explain under#21 Remarks) FROM TO DESCRIPTION(cojo
4.Date Well(s)Completed:pi-�_ �111 ID# O fL r.hardness,soillrock min Am etc.)
5a.Well Location: -5 0 ft. C,
,1`des rand arms LLC— JFL , ft
Facluly/uwner Name
Facility ID#(if applicable) ft. ft.
7
I Address,ss,City,and Zip ft. ft. L-L)
Parcel Identification No.(PIN) 04[Z'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N W
6.Is(are)the well(s)I@Perrnanent or
Temporary Signature ofCcrtified Well Contract
7.Is this a repair to an existing well: or BY signing this form,I hereb),certify that the well(T)was(were)constructed in accordance
Yes (N, with 15A NCA C 02C Phis is a repair,fill out known well construction has been provided to the well owner.
fthisjorm.
repair under#21 remarks,section or on the hack a *0100 or 15A NCAC 02C-0200'Veil Construction Standards and that a
ru maho).nd lain the nature ofthe copy ofthis record
�4­For Geoprobe/DPT or Closed 23.Site diagram or additional well details:
-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I Gw-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: A
9.Total well dep0?-1,0_w land surface: SUBMITTAL INSTRUCTIONS
For multiple wells list all depths ifdifferent(e � -)
ramole_3@200,and 2@100,) (ft 24a.for All wells: Submit this form within 30 days of completion of well
40 construction to the following:
10.Static water level below top of casing: 1,
ffivater level is above casing,use­+- (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 6 1/8 1617 Mail Service Center''Raleigh,NC 27699-1617
(in.)
24b.For Infection 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, construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Under girhind injection Control Program,
13a.Yield(gpm) IL578 Method of test: Air Flow 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water SURRIV&Injection Wells: In addition to sending the form to
13b.Disinfection type: Chlor Tabs Amount: 1 1/2 Lbs the address(es) above, also submit one IcO'PY of this form within 30 days of
— completion of well construction to the c unity health department of the county
where constructed. r I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016