GW1--01862_Well Construction - GW1_20240322

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WELL CONSTRUCTION RECORD GW 1 �w
I.Well Contractor Information: For Internal Use Only: ' t?l f
Robert Teague j
IIWNi
Well Contractor Name 14 ZVATE1tp cx ..
FROM TO i t` 'Y- ,. ,.. 't" 'a,
2857-ADESCRIPTION ""
NC Well Contractor Certification Number ®,‘
B&K Well Drilling Inc kr
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llME
Company FROM TOs eUR®
P yName DIAMETER "' x
0 fG ,O Co 2.Well Construction Permit#: �3 ® SDR 2t
List all a " BR 51i611t r.:,applicable well constraction permits i e FROM TO C*.
( UIC,County,State,Variance,etc.) 111111311111111111111111611111111110111111111111111111DWM
3•Well Use(check well use): •
Water Supply Well: 11111111111111111 1°
111111111111111111111111111
. Agricultural ?
FROM .,,r.:.,. "`c' tires - ;,.;aS7 R„
�Municipal/1Wate M T© DIAMETER ® M'°�._:
Ill Geothermal(Heating/CoolingSupply) SLOT ��
PP Y) Residential Water Supply(single) --
,> Industrial/Commercial °Residential Water Supply(shared)
�hri••�ion PPY( z��© --
Non-Water Supply '"� ;
Well: FR© TO Mks ,' 1C asp ,_.. z.,i
*Monitoring ©� EMPLACEMENT METHOD&AMOUNT
Recovery Injection Well: ®®
alt Aquifer Recharge 11111111111112111111111111
-
',Aquifer Storage and Recovery °Groundwater Remediation
11. Salinity Barrier IFROM Dll $ ;
Aquifer Test FR® TOmminimil
ble s mumma resrtl
ar Experimental Technology �Stormwater Drainage ® EMPLACEMENT METHOD
Su
1111.111111111111111111111.111
I Geothermal(Closed Loop) bsidence Control ®©
>l�Geothermal(Heatin• Tracer
Coolin_Return) T"Lt)Cr at rs3 si
*Other(explain under#21 Remarks) FROM DESCRiiiii (color,hardness, AWWg
4.Date Well(s)Completed 0 ft• ft ess soil/rock t•e : in size sees
Well ID#
fD0 �
• ZllLocauOn, ft' � {r 6/��
li 6^ft ft.
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Facility/pier Name _
�e 1 I L FactlitylD#(if applicable) �©
4 Physical Address,City, d Zip Q/ ®®
®� l/ / (L
County �� wxl'131.VIAn 1111111111.111
`?xw .,` 4; gi f ,re:. �-�
Parcel Identification No.(PIN) #___
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.CertificaSon:
W
N
6.Is(are)the well(s) pe nent or °Tempora at g-
ry Signature of Certified Well Con r
7.Is this a repair to an existing well: �y� oratDate
he well(s)
If this u a repair,fill out known well construction information and ex ain the nature of the opyrofthigs record has been prowled tohetwell owner.
(were)constructed in accordance
o with ISA NCAC 02C.0100 or/SA NC4C 01C.0200 Well Construction Standards and that a
repair under#2/remarks section or on the back of this form
8.For Geoprobe/DPT or Closed- 23.Site diagram or additional well details:
construction,only 1 GWor C needed. Indicate TOTAL Wellsl having the same You may use the back of this page to provide additional well site details or well
drilled:_ NUMBER of wells construction details. You may also attach additional pages if necessary.
land surface: SUBMITTAL INSTRUCTIONS
For multiple wells list all depths scent(example 3@200 and 2@I00) (ft•) 24a. For : Submit this for
9.Totes!well depth belowm within 30 days of completion of well
10.Static water level below top of casing:40 construction to the following: I
If water level is e casing,use'+ (ft.) Division of Water Resourcels,Information Processing Unit,
I L Borehole diameter: __ 1/8 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
12.Well construction method Air ROtar(i 24b.For Injection Wells,
In addition to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,et above, also submit one copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY:
Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm) 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: Air Flow
24c•For Water Su 1 &In'ection Wells: In addition to sending the form to
the address(es) above, also submie co
136.Disinfection type: Chlor Tabs r 1/2 tJ� it or
Amount: completion of well construction to the county health department of the county
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources
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Revised 2-22-2016