GW1-2021-03382_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Reuben W. Clayton, III 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2241-A I' 8"Ll lO�,°'t tCtvsz
ft ft.
NC Well Contractor Certification Number 15.OUTER:CASiNG for multi-cased;wells'OR LINER if a 7icable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ,t fL S' ft O ! in I A-7-'
_ �9 16.INNER CAS G OR TUBING -eothermal closed400
2.Well Construction Permit#: 4—_ J1JP Z/di OP 01 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.) & It. in.
3.Well Use(check well use): & & in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural icipaVPublic U & ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft lo•
Industrial/Commercial gResidential Water Supply(shared) <dS7GROUT-
`Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: & L 3 & C,,�f//�f
Monitoring DRecovery ft ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
`19;SAND/GRAYELPACIC if a` Gcable '
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft
_.Geothermal(Closed Loop) Tracer 20.'DRILLING,LOG attach additionsl sheets if necessa
Geothermal(Heating/Cooling Return) r30ther(explain under#21 Remarks) FROM TO DFSCRmnox color,hardness,soiltrock type,grain sae,etc.
® ft. '7 it A 4�n Ce-4 V'
4.Date Well(s)Completed: Well ID# -7 & q` ft 7,,of✓t/
Sa.Well Location: ft -7 ft 64 7y���O�oC
Facility/Owner Name Facility ID9(if applicable) & ft. I'- °� �f_
r
Z.DO���O�Rs D2 /1�iot�s`L� ZZ3?,0 it ft
Physical
/Address,City,and Zip It ft 1 7 021
21.:RE11VIARKS .
County Parcel Identification No.(PIN) »¢ - ivil processing esslrlc� n
li
DVVR ec;'v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat//tong is sufficient) 22.Certification'
a q" N T%®,Xd`/7 749 W
6.Is(are)the wells) Permanent or [)Tempo;�N.
Signature of Certified Well Con ctor ! Da
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: [3Yes or with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 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,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMPPTAL INSTRUCTIONS
9.Total well depth below land surface:_,,?01Ci (ft) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
lfwaier level is above casing,use"++"/I ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: O (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
��2 n D 7�� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: „ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
YY)WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Z Method of test:eW,7Z W1 7f � 24c.For Water Sunoly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forts,within 30 days of
13b.Disinfection type: '764�10114T11 Amount: /Li-d 2, 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 Revised 2-22-2016