HomeMy WebLinkAboutWELL-07-2022-175148.TIF WELL CONSTRUCTION RECORD [GW-1) For Internal Use Only:
1.Well Contractor Information:
Robert Teague 14,WATER ZONE:
FROM TO nFiCRTPT1ON
Well Contactor Name J l_S tt. 1 r [ :::
i 5.B 8 K Well Drilling IOC l3 /,Y
NC Well Contractor Certification Number 15.OUTER CASING(for mott3-eased welts)OR LINEi1(11
2857-A FROM To DIAMETER TIUCKNESS MATERIAL
0 ft. _ft' 61/8 in' SDR-21 PVC
Company hams 16.INNER CASING ORTUDING(geothetmatdosed-beP) •
2.Well Construction Permit p;
Q1 `D"t 1? — )^. i LA FROAI TO DIAMETER THICKNESS MATERIAL
/�]a` ! g ft ft In,
1 cat all applicable well construction permits 4.e.U1C.County.Stare.Vanunce•air 1
ft. I.
in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE^' THICKNESS MATERIAL
0Agncultural Municipal/Public ft. ft. la.
DGcothcnnal(Hcating/Cooling Supply) csidcntial Water Supply(single) ft rt. in.
0Indusuial/Commercial Residential Water Supply(shared)
1 lmgatiun • FROM TO MATERIAL EMPLACEMENT METHOD 4 AMOUNT
Nun-Water Supply Well: It. ft.
Monitonnq. DRccovery ft. ft.
injection Well: ft. ft. 1
Aquifer Recharge QGroundwaterRemedi4ion 19.SAND/GRAVEL PACKGftup&able) . •' ' .•
'‘
Aquifer Storage and Recovery OSalinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
3Aquifcr Test JStormwatcr Drainage ft. ft.
Experimental Technology Subsidence Control (t. tt.
Geothermal(Closed Loop) Tracer -24L'DRTLt.1NGLOG(attach'a ti000tsheetaifiiee�iay7'• •'' .• '
FROnt TO DESCRIPTION color. nen.rerVrock aye,/rota Oa,etc.(
Geothermal(Heating/Cooling Return) f Other(explain under 421 Remarks) ft. , 5- ft. f(
4.Date Wells)Completed: f 2 / . yell imp l 5q ft' D-0 5ft. NrG 6 l c- tt
5a.Well Location: D(D)f t. 70.5 ft- j')u rCi,4.iO-C—t ,`L-e
cc-kJ/NI c1-,Urek It ft.
Factlity/04,ner Name Facility l0K(if applicable)
ft. ft.
?o_5 8 Rr,.\-191-L L i. vC..V6 Y 1 ft. ft. ,
ft. ft.
Physical Addrecs.City.and Zip
Cr,,, la_2 Sl RF3bI.#RKS
County Parcel identification No.(PiN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.
Certifcation:
N W /f
/t_a $ •a`i ^,)-
SutumofCelificdWell actor Dow
6.Ls(are)the well(s)0Permaaent or °Temporary
By signing this(orm,1 hcrelry gear(.that the wilful was Neer/constructed to accordance
7,Is this a repair to an exisdng well: 0Yes or Na nith I SA N'CAC 01C.0100 car 114 NCdC 02C.0200 Well Cunsrrucriw ,Ia e StanJar and that a
I/this is a repair,fill ow known well construction tnfnrnation nd native lain the nate of the copy of this remold ira.t been prowled to the will onner,
repair under 021 remarks se ctlun car an the hack of this farm. 23.Site diagram or additional well details:
8.For GeoprobelDPT 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 details. You may also attach additional pages if necessary.
construction,only 1 W-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 3 OcSUBMITTAL INSTRUCTIONS
(It.)
9.Total well depth below land surface: 24a. For All Weds: Submit this form within 30 days of completion of well
Fee mu/tyt/r aide her all depths ifdiffrmnt t:xample-3`2on•and 2Q100') construction to the following:
10.Static water level below top of casing:
40 (ft) Division of Water Resources,Information Processing Unit,
if.w iet lewd is a/Mre toting,as•-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 21b.For injection Wells: In addition to sending the form to the address in'_13
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:
tie.auger.roiary.cable.direct push.etc.l
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: Air ROW 24c. For Water Supply&injection Wells: In addition to sending the Minn to 13a Yield(gpm) 5 the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs Amount: 1 tf2 Lbs • completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form OW-I North Carolina Department of Esmrontnental Quality•Division of Water Racvrrei
Revised 2-22-y016