GW1--04986_Well Construction - GW1_20230807

1
l Print Form
'WELL CONSTRUCTIION RECO!':!II (GW-f For Internal Use Only:
I.Well Contractorr Information:
/
Reuben Clayton, HI 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2241 aA i<.5•ft. `fr ft ,,JAy r 6 4 i -
ft. ft
NC Well Contractor Certification Number
Aqua Drill,
Inc. 15.OUTER CASING(for multi-cased wells)OR LINER Wan licable)
FROM TO DL�METER THICKNESS '1 MATERIAL
Company Name T1 tt �� �n �7�j - '�
#lt✓ 16.INNER CAS G OR TUBING(geothermal closed-loop)
2.Well Construction Permit#_£' / 1.��3-a�ja(- FROM TO DIAMETER THICKNESS .MATERIAL
List all applicable well cansintction permits(Le,U/C,County,State,Variance.etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QIMpi cipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) icesidential Water Supply(single) ft ft. in.
Industrial/Commercial I DResiderttial Water Supply(shared) 10.GROUT
: Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft247 ft. e6.7 -M
Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Rechargeft. ft
qGloundwaterRemediation
Aquifer Storage and Recovery . Salinity Barrier19.SAND/GRAVEL PACK(ifapplcable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test :oStormwater Drainage ft. ft
Experimental Technology ,0SubsidenceControl . ft. ft.
Geothermal(Closed Loop) luTracer
20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ()Other(explain under#21Remarks) FROM TO DESCRIPTION(color,t.ardnessso;v„cx type,Q„ineke,etc.)
� , ® it: -7 ft A > i' sg
4.Date Well(s)Completed: 3 24/lYWell ID# 7 ft 4 ft. 7el,5' C /i
5a.Well Location: g Z ft. ft. ! ,e �9 /�
/MM 'y C -4Y.PG(:134d1+✓ma y (�1���/i'•�6�/� ^�.
iitil e IlI66 4 R.E 7,J°L • 22_, ft• , GoS• ft. .2 ,- C�242...-4-e;,
Facility/Owner Name Facility 1Db(if applicable) ft. ft. r-- I::r('f p i+g ( •',
•
/.rcL, � ,to oiai v/'��G f�30-/y ft. ft. i
Physical Address,City,and Zip ft. ft A U U 1 O
zed CFe.j✓Gt C t�yr 21.REMARKS
County1F)rCS A`a?:O Prr•::=f:;-:,:::,4 u',.
Parcel Identification No.(PIN) r .,,4-1,.,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor Rafe
� 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: QYes or rag with ISA NCAC 02C.0100 or iSANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fdl out known well construction information and explain the nature(tithe copy of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this 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: Z-6.52- (ft) 24a. For All Wells: Submit this form within 30 days For multiple wells list all depths ifdijferent(example-3@a200'and 2a,100') y OfCOmplettOnofwell
construction to the following:
10.Static water level below top of casing: go: (ft) Division of Water Resources,Information Processing Unit,
if water level Is above casing,use" // 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G�/y' CD.) 24b.For iniection Wells: in addition to sending the form to the address in 24a
12.Well construction method: .A' ems
d P•" � above,also submit one copy of this form within 30 days of completion of well
construction to the following: •
(i.e.auger,rotary,cable,direct push,etc.) g
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY�r WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
/13a.Yield(gpm) t Method of test / (,y 24c.For Water Simply Sr Infection Wells: in addition to sending the form to
,a., the address(es) above, also submit one copyof this form within 30 daysof
13b.Disinfection type: ��O`/.7�/d Amount a az_ 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