GW1-2022-10792_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD(Gw-11) Por Internal Use Only:
1p.��Well Contractor V91�/�IInformation:
Reuben W. Clayton, III 14.WATER ZONES f
Well Contractor Name FROM I To I DESCRIPTION
2241 mA fs ft 3/� ft /S G!�
NC Well Contractor Certification Number
Aqua
0+ Inc. 5.OUTER CASING for multi-cased wells OR LINER rf a livable
Aqua ®IIII, 1 FROM TO DIAMETER THICKNESS MATERIAL
Company ft l ft /' in t C-.
Corn Name �
.INNER C G OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER Tiflaa EBs MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc..) ft. ft in.
3.Well Use(check well use): ft. ft
Water Supply Well 17.SCREEN
FROM TO DIAMETER sLOT SIZE THICKNESS MATERIAL
Agricultural �M cipal/Public ft ft, in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) h ft in
lndustriaVCommercial Residential Water Supply(shared)
18.GROUT
' E I -
IILI tlOn FROM TO MATERLfL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Wc11: ft 2<7 ft .r v14-9
Monitoring DRecovery fL &
injection Well: a /—gs--
A uifer Recharge gGroundwater Remediation ft. W
Aquifer Storage and Recovery Salinity Barrier 19.SANWGRAVEL PACK if a livable
FROM TO MATERIAL EMPLACEMENTME'rHOD
Aquifer Test oStormwater Drainage ft ft
Experimental Technology Subsidence Control ft &
Geothermal(Closed Loop) Tracer 20.DRILLING LOG iatt2eh additionatsheels if necessary)
Geothermal(Heating/Cooling Return) - Other(explain under#21 Remarks), FROM TO DESCPJVI70N color,hardnesA soiurock type. lmsire eta
0 P. ft
4.Date Wells)Completed: 2 Nell 1D9 ft. yJ ft.
Sa.Well Location:
4e-- '4V 9, fL ft. ftV.�/�z�
FaclitylOwner Nam Facility iD9(ifapplicable) ft &
& ftV+
Physical Address.City,and Zip ft fL -
lt�l � 21.REMARIG4
County Pat=1 Identification No.(PIN)
96.Latitude and longitude in degrees/minutes/seconds or decimal degrees: :-
017well field,one latllong is sufficient) v=
22.Certification:
N
6.Is(are)the well(s) rmanent or mporary Signature ofCettified Well Coi ctor fe
By signing this form,1 hereby terrify that the wells)vas(were)constructed in accordance.
7.Is this a repair to an existing well: OYes or or with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that o
If dris is a repalr,fiQ out known well construction tt formation and explain die nature of the copy of this record has been provided to the well m:mer.
repair under d21 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
constriction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
/ SUBMITTAL INSTRUCTIONS
9. multiple
well depth below land surface: 3C0' ft) 24a. For All We11g: Submit this:form within 30 days of completion of well
Forr rnulriple wells lint all depths tfdifferent(eranrple-3Q200'and 2@/00')
construction to the following:
10.Static water level below top of casing: GLt e
If,varerlevel is above casing,rtre"+^ (fL) Division ofVPater Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _(in,) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this farm within 30 days of completion of well
lie.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
131.Yield(gPm) Method of test:<i' 24c.For Water Supply&Hniectioit Wells: in addition to sending the form to
the address(es) above, also submitl'one copy of this form within 30 days of
13b.Disinfection type: Amount: 145'®.?— 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