HomeMy WebLinkAboutWELL-07-2023-201286.TIF 111?I.I,CO1Sl'k l Print Form
C'l lO�' RF;(Y)I21) Cr11 I For Internal Use Only.
I,Well Contractor Infn mil thin:
Robert Teague 111
lc WATER ZONES 1
Well Contractor Nano 141 s ru ( u►.k elruo+
2857-A a5 on. I fit.
Q � =G --rO k.-�
NC Well Contractor Certification an Number S ft. I t
B & K Well Dulling Inc 1!•OUTER 5SIN (faenalAi��eikORLINERkgapplIcabiel
room 110 DIAM1 TIN THI(K\IS% MATERIAL
Company Nana 0 R Oft, 6 tl In- 150R•21 PVC
��* j�+ L16,INNER CASING OR TIi9ING(pothering!clased400p)2.Well Construction Permit q ` j 3 FROM 1 TO I OUmf TER mit 1048s
fIJI,ilI applicable writ runnrurnan pet MILS p r U/L'.CountySmh• Vaa fit. H. In
anrr,err.) MATERIAL
,
3.Well Use(check well use): It. ft. In.
Water Supply Well: 17-SCREEN
❑Agricultural MunicipafPublic PNO\I TO DLHIL rrR SL(rT SIZE THICKNESS MATERIAL
Geothermal(I-ieating•Cooling Supply) @Residential Water Supply(single) IL Residential
ft. la.
ft. ft. In.
❑lndustriaVCorTuncrcial
Residential Water Supply(shared)
IIIml;atton IL GROUT
FROM TO MATERIAL EMPLACEMENT METHOD a AMOUNT
Non-Water Supply Well: rt. ft.
DMonitoring Recovery
Injection Well; H• fl.
°Aquifer Recharge DGroundwatcr Rt:mediation fit fit.
ID Aquifer Storage and Recovery Salinity Barrier 19.S lYD/CRAs'EL PACK pf applicable)
FROM TD MATERIAL EMPLACEMENT METHOD
0Aqutfer'fast DStomtwater Drainage ft. rt.
ElExperimental Technology DSubsidence Control ht.
It.
Geothermal(Closed Loop) 0 Tracer 20.DRILLLNG LOG(attach additional sheets If necessary)
°Geothermal(Heating/Cooling Return) El Other(explain under 021 Remarks) IK011 rn Uh-ACRIPI ION(snits.Gard s�wlUrocA Her,grain Nu,etc)
/j� 0ft � f'� d i ` l.0C
4,Date Well(s)Completed:// �( Well IDk f t, r) D•
Sa.Well Location: r1ft. S fl.
•
WA aUc>.\/ fay,11 �,,.- d�L1' �.z,
3 6 S'' 1-j�� S" ;if�-� 151(
Faalloyapwncr Narnel r \ Facility IDa(it-applicable) ft. , ft.
7 r)Cj /) K 1� N 3cy ft. n.
Physical Address,( es City,
,and Zip l rt. ft.
Q'CCX—`-�'\7 Q 1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,ortc fatlong is sufficient) 22.Certifeatio-r"-----
N W ,,,..c
Le.,
6.ls(are)the well(s)0Pcrmanent or Temporary Signature of Certified Well Contra�er Date
Ri signing this form.I harchvi cerriJv shot thv mills,Nat(were)cuntirucred rn ace'ordartee
7.Is this a repair to an existing well: Dyes or No w 15.4 NC4C 02C.0101r or 15A NCAC 02C 0200 Well Cnnstrucaan S:undards and those
1f this is a repair,fill out inm,n well consructian information and r with air the nature of the cape of tbrr re""hat brc'n prnride/u,the well unser.
repair under a21 remarks section or on the back of rho form
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-I is needed, Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6s-- (fit•) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple wells list all depths if different(example.3.?200'and 1C1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use""' 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 1/8 (In.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
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:
li.e auger,rotary.cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Y 0 Method or test: Air Flow 24c.For Water SpppIv& Injection Wells: In addition to sending the form to
the nddress(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ChlorTabs Amount: t tizLbs completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Rcsued 2.22-2016