GW1--01864_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD GW_1
I.Well Contractor Information: For Internal Use Only: x :CO kl
Robert Teague I
Well Contractor Name ;'F ;Ws k x ,nr
Z85t_ FROM TO DESCRIPTION
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A - ' �4 r soft,
NC Well Contractor Certification Number ® , dzi ft
B&K Well Drilling Inc T1A .:
R SI;farm -disc eelts''.FROM TO -0 C,Ess';1; :i, ---
Company Name DIAMETER '
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2.Well Construction Permit#: SDR 21
List all applicable well construction permits(i.e.UIC,CoupFROM TO } [
County,State,Variance,etc.)
©® DIAM®._•Tf31CtINFSS ^'_^.,:,s. rnm
3.Well Use(check well use):
Water Supply Well: 111111111111131111111311111111111.1111111111 AI Agricultural IREE19 big "°
�Municipa l War c FROM TO DIAMETER IIMMEMIlialitatiii
It Geothermal(Heating/CoolingSupply) SLOT
PP Y) Residential Water Supply(single) --
1 Industrial/Commercial Residential Water Supply(shared)Irri_ation PP Y '1{SGltf)D'>`x®
Non-Water Supply Well: f
FROM TO _° xT.z?,`i�3. y-..", &.
©©� EMPLACEMENT METHOD&AMOUNTS.
Monitoring °Recovery 11111111111111111.11111111111
Injection Well: ®®
it Aquifer Recharge
i Aquifer Storage and Recovery °Groundwater Remediation ®�
Salmi B19IS1�IDICY�,ty artier
Aquifer Test ® TO lire ., ?c , ' s ;}
OStormwater Drainage ® EMPLACEMENT METHOD
If Experimental Technology
I Geothermal(Closed Loop) Subsidence Control
Tracer 11=
$Geothermal(Heatin•Coolin•Return) ( FROM L©' `rtiroasC;sfreety ., HV;Other ex.lain under#21 Remarks) TO DESCRIPTION color,hardness,soiU k{' size,
dr-a
IMBLIMINOMMIIIIIIIII
( A.e,_rain size etc)
4.Date Well(s)Completed:I' 3 % • 2-
Well ID# F ft. MiggranEt `
apinsm
5a.Well Location:
IIIMFacility/Owner Name I
S� Facility ID#(if applicable) �©
-s _a '� ®®
Physical Address,City,and Zip
L. — ti ®© MAR 2 4
ZOZ-
County .W t s `,< ctc
Parcel Identification No.(PIN) "
IIt+"#I YPtm.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t^v1 Pr 4��U .
(if well field,one lat/long is sufficient) v
22.Certification:
N W
6.Is(are)the well(s) penent or Temporary Si of Certified Well Contractor 1 •.3 1 - e1-
7.Is this a repair to an existing well: y� orBy we Date •
If this is a repair,fill out known well constraclio®formation and lain the nature of the opyt of this record has been provideddt that
etwell owner.
(were)constructed in accordance
No with ISA NCAC 01C.0l00 or ISA NCAC 02C.0100 Well Conslruclion Standards and that a
repair under#21 remarks section or on the back of this form.
8.For Geoprobe/DPT or Closed-Loo 23.Site diagram or additional well details:
p Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only W_1 is needed. Indicate TOTAL NUMBER of wells
drilled: construction details. You may also attach additional pages if necessary,
9.Total well depth below land surface: 3� SUBMITTAL INSTRUCTIONS
For multiple wells list all depths rfd fferent(erample_3@Z00'and 2�100� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: 40 construction to the following:
If water level is above casing,use"+" (ft.)
Division of Water Resources,Information 27699-1617 nit,
11.Borehole diameter: 6 �$ 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
(in.) 1
Air Rota 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ry above,clso submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,1 Raleigh,NC 27699-1636
the form to
13a.Yield(gpm) Air Flow Method of test: 24c.For Water SuoDly&Iaiectinn
13b.Disinfection type; Chlor Tabs' the address(es) above, also submit oeecopy of this form on to sending
0 days of
Amount: t 1/2 Lbs
completion of well construction to the county health department of the county
where constructed. I I
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Rcsourccs
Revised 2-22-2016