GW1--01865_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: fnorrrt
1.Well Contractor Information:
Robert Teague
14 WATER CilttES MM I ' :S ::. IMIVIII EXA,M•A K , ;Well Contractor Name FROM TO DESCRIPTION
2857-A '5_c)it• 24 t") ft•
-NC Well Contractor Certification Number Ir-1�t 4$C�ft•tl S `d 11,2"
I5 OUTER'CASING(foe�mutii eitie'd-wells)"ORL1NEW(ftup•licablef 4 < ., , ,'i"
B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft fL 6 1/8 to SDR 21 PVC
® _ c�I1 �� :16 INNEK CASING;OR 3 t1SING'(#eothertiiakkelosed•146 . tW'`<*K. .„ -;m,.e .,1 a
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State, ariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 511,SCREEN EI 4 ,r„».x .g,.,.'.., i.: .. 4 ..- ,
A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gn °Municipal/Public ft. ft. in. .
°Geothermal(Heating/Cooling Supply) ISIResidential Water Supply(single)
ft ft. in.
°IndustrialCommercial °Residential Water Supply(shared)
°Irrigation FROM TO "'
MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL
°Monitoring °Recovery
Injection Well: ft. ft.
°Aquifer Recharge °Groundwater Remediation ft. ft.
Aquifer Storage and Recovery °Salinity Barrier I,.9 SAND/GRAVEL"'PA�df appIicable)..�.4_.;s z A,r . r;;,,t,,,.r;; MMI l k lt
FROM TO • MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20 DRILIs'INGEOG(iteach`ladttioiiatiskeelsifiiices lr ,a,
FROM TO sat'y)rs. .F =..' " tt etc.).i„I
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ` 4ESCRIPTION(color,hardn oil/rock type,grain size,etc.)
4.Date Well(s)Completed: • 3 -ailWell ID# /Vc\—ft. ^��^�-tt. J �`J , `,e k
5a.Well Location: •a, -Set' j9-1 5 rc14i' r a' 024.,0 i l 4.—
f�ekv1/ j� s 6 `• ham`'^
r fG it.
Facility/Owner Name Facility lD#(if applicable) S^- it 6 rC e ft k cAs—L S /P/G'`
i�- �}H 5 )oCLI-�CIX V�y �")�� 6o`b.� `2(JJ t tea.- ,-F hc.�t�/ r.,r
Physical
_ a Address,City,and Zip ft. ft. /
eOa'c.Lct.)1 OA_ Ames,
vt21•rtREiV1 r,4wz wm ro .gragLI N,M.a%Iwzw,;M:>
County Parcel Identification No.(PIN) 1..". i" `••',r"„ ft*,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �' °' �s�
(if well field,one lat/long is sufficient) 22•Ce MAR 2 2
N • W �/ 2024 ?.G
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Contractor 'Date CYtFrCt;'n'�G:,
By signing this form./hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information a d lain the nature of the copy of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT 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 ifnecessary.
construction,only 1 W-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: 710 (ft) 24a. For A11:Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifd(erent(example-3@200 and 2@/00)
construction to the following:
40
•
10.Static water level below top of casing:
Ijwater level is above casing,use••+ (ft•) Division of Water Resources,Information Processing Unit,
6 /8 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 1
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Rotary above, also 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: I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
/� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1
V Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to
Chlor Tabs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: t 1/2u's completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016
i