HomeMy WebLinkAboutWELL-03-2023-192105.TIF . 1{17 �1 L� l: / PrInt ruin]
t l oz. - "ff3 - r35 /
WELL CONSTRI CTIO\ RFCORI) iC\1-Ii lot Internal Use Only:
1.N ell Contractor Information:
Robert Teague 14.WATER ZONES
'.1;:i(",•.:tT:::,\am: FROM . 10 HI SCRII'llO\
2857-A It. It.
\a"w;.1 i,•'!tsar)L.ri$:c:Ion\-.-..h r
IS.OUTER CASING;(for multi-cased wells)OR LINER EapellcabIll
B&K Welt Drilling Inc FRIISI , TO ' DI%Nil T1.R I THICK\Iss MAIIKISL
C omryri',Inc 0 (t. � ' ft. 6 La tn. SOR-21 pvC
I h.INNER CASING OR TUBING(jeothermal closed-loop)
2.Well Construction Permit a: ) 7) )t O 'S _txost , TO I DI%%IfTER TIIICK\FSS 114TER141.
i.otatrd,IY,c,IN't.e11 r,vv trawl,.rr,".:u F r L11...Cuunn.Starr.l'ar,;;rr,r.elt 1 ft. i n. i in.
3.►►ell too(check well use): ft. h. in.
Water Supply Nell:i3
RI IT.SCRFEre
roost
IMAMIMAMI'Tta SLOT SIZE THICKNESS NI VVDaAgnctlltutal Q\tunictpol Public ft. io.
CDGrothcRnai(Flerting Cooling Supply) ID Residential 11'ater Supply(single)
(t. ft. in.
alndustrial Commercial 0Resriennal Water Supply(shared! -
Ili.'GROUT
rilmgntion FROM 10 MA1ER111. EMPt.ACFME\T11CtHODt&MOE\T
Non-Water Supply Well: ft. n.
O4lonitonng DRecovery n. n.
injection Well:
ft. j ft.
A Recharge Groundwater Rcmediation I
Aquifer Storage and Recovery 19.SANDrCRAVEL PACK(If appllnble)
gquIfcr
''aP �Sallnity Barnet FROM TO 11ATERr•1L FIIPLACFME',T METHOD
Aquifer Test gEalpenmental Technology ❑$tornvwater Drainage n. n,
Subsidence Control It. ft.
Geothermal(Closed Loop 1 Eirracer 20.DRILLING LOG(attach additional sheets If nett-nary)
°CrcotheuliHeatine'CoolincRrturn) nOther(explarnundert?1 Remarks) tB01t ) to IllSC)4I 1l0\(color.hard.t wit rock
m
3.Date Well(s)Completed: D'),Cy' 41 Well LDR S ft. I n. L4_7.4!
5a.Well Location: ft. IL trtr
oG-DR_,p Cons)rucE� GA (-Lc- sk 1. 1. .e ____
Fa:dni llirxt Na Fucihll iD`o III appl.cablci tEr It.
)�Wc-\ E c _ti i4d "! (rrt)\ ft.
Physical Address.Cii .And Zip Ft. ft.
C1A 1„1 CA 'i/? 1131.,rr 3 11.RESIARK.S
County PsreclII ntiEcationNo(PI\I
5b.Latitude and longitude In degrees;nusutes/seconds or decimal degrees:
(IrIccil field.One laclo+g a sufficient) 22.Certification:
N _a5, )3
6.1s(are)the well(s)0Permanent or �Temporan rarcofCrndiJt►cflL'o Fire
k+ v4Xr.,nl;thin,Ibrm.i hr,:hl,rrurJ, (hal die null),,1vac hint.)nr ,crachrsi in acciadancv
7.Is this a repair to an existing well: Wes or No .stir 15a.VC4( USC Oltin or/51:1t t('t7;C' r);UO Hell Causrrucnan Srrnjardr and Mat a
llrku u a rrpXr,fili aid LOOM is/I,°cumin FIRM 1R,'11,a4i;1u4 t. eipldrn Ike natrav u/the "VI I+1 rho,r,un1 Ad,h.•rn pr,n ided w rhr nrll(Jr ne•r.
rips:)under I l rrm.vtic,ettw,or Or,the:.ve(at this foals
23.Site diagram or additional well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells has ing the same You mac a+e the back of this page to pros jde additional well sue details or well
construction,only G►►'-1 is needed. Indicate TOTAL SURIBER of wells construction details. You n1a1 also attach additional pages if necessary.
drilled: S B\IIT-FAL INSTRUCT1O\S
9.Total well depth below laud surface: 2.9- (ft.) 24a. For All \►ells: Submit this form within 311 days of completion of well
Forani.iti/'- nr1G lot all depth,Ifj rerent,e 4aterpir•3.ti 100 and:Ml!tilt i
construction to the follow mg:
10.Static water lesel below top of casing: 40 (ft.)
Uilision of Water Resources,Information Processing Unit,
Ifralrr level if 41401r ccxMg,use 1617.Hall Service Center.Raleigh,NC 27699-1617
II.Borehole diameter: 6 1/8 (in.)
241). For Injection►►'ell1: In addition to sending the form to the address in 24a
Air Rotary ahosc,also submit one copy of alio form within 30 days of completion of well 12.Well construction method: construction to the following
(ic.auger,roar).caste.duvet push etc 1 E
Dlsision of Water Resources.l aderground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test: Ar Flow 24c.for%liter Suopll & lniec Lion 'sells: In addition to sending the form to
CMorTabs , •: the addressles) abuse. also submit one copy of this form within 30 days of
Lbs 13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constnicted
Form GW-I North Carolina Dcpanment of Fesironrncnrai Quality.Disown of 1►a1er Resources Resisod 242-2016