GW1--02802_Well Construction - GW1_20240506

WELL CO�TSTRUCTKo 1 ECORID(GW.i) .:
For Internal Use Only
• •1.Well.Contractor Information:. . :
• . • :Reuben W. Clayton 'II . 175ki.' .• . .. • - .. : • • • 1 -
7� E(�. �.r7� 1 oWATERZONSS" . - - - - • ' • • • - -
• . . -. Well Contractor Neme. '.. .. . : -.
. FROM TOli: DESCRiPIION...
2241.-Ai : )-c• . . .: ..: : . . . 1�-:�:: • • • : • • . .
NC We- ...eactor Ce•itificatioa Namtie .. .. . .. . .. ..
:. 15.OUTER-CASING(for muk seal wells OR•LINER Of cable): .Aqua-D lh:InC.'.. : ' .FROM• •_ To . -DIAMETER-:• - TffiLR07ESSt: , "MATERIAL
: Company Noma ' • -• s, •tt.I. 9 in•- : .
• I CASING.O
- .•. • well COnStructiOnPErmltth :... _: ' . : • .• •• • ••..FROM ER .^Ip G{geot6ermd aimed-loop) �
:'GCstall.appJiacblewell ttmclio)?pemd(er(Le.:UIC,CormrySIate,•VarfanO,•r1e) O- y fp DL�MBTEir . ._ -
•
-3.Well-Use(ebeck well.use) . : : . . • :•• •• -. rt.. • & .In,.
:.• Water Supply Well:", : ._' .,17 SCREEN •.•: Agticuhimal.'•. :; :•. DI•.:. - 'ER SWTSII�E -THICi@ E:•, MATERIAL -
. : :. � � • itaUpabli¢ � .
FROM TO
M Q � tt• 1p.,
Geotht mial(fleeting/Cooling Supply): • identtal Water Supply(single). •ff, .: it' ' in:' :
-. Industrial/Commercial :`:.
E > stet Supply(shared)
Irrigation : — •
a1W
FROM TO MATEAW. HNlIAC6l11PdNTML?HOD1gAMOUNT. . '. Non-Water 13upply Well• •
Monito ing Recov
jectioa. .
• . er eharge• . .. : . fa .
•. . Aquifer.Rc
.� �Groiindwaber Remediation' : . ": -±.• . :-• . . .-• .. - . ..
" Aquifer Storage and Recovery �Sahmty Bamer SAND/GRAVEL PACK fd dinbk) _
uife'r Test :.. . . °�►
' FROM ..To
: ' - .. : Stonnwate.r Drainage.•
Experimental Tcchnol
�', .•.---� -.: : Subsidence Coirtiol: .-•. • • ' R :. `..ft • TEnrAL .
EMPLA- CEMLNr MF9HOD
:. Geothermal(Closed Loop) ••.. : •.. •• , Tratxr.: : .
' ': . • 0,
•l l• . .. . .•
. 2 DRILLING'':G(,nacl.ddinaaal ifoaes.. .
. Geothemtal ) :_.
(Heating/Cooling Return), �01her{expl�n tinder#21 Remarks); m •DasctupTloat cwtor.e,�,,rsanodc sins uk.he.aa) .
:. 4� .Date Wells)Completed: : Weil m# .
Sa.Well LocatIoa: :-tti • tt•• • • .
4 $
•
•
:.: i. A�T7P�•�e:;d,..+v.: :. . • • tt tt: it fi LQL4
. :facility/Owner Name
FaabtyIDIi,Cif applieable) f4
• : :- 73A(J."/"2-2;d.�3.?� . . - • - �Y� ��. 9 •
- ' : Physical naamss,city;acid Zip•.• . • :• .• .• • • • • •.• •.. .ft. .-• ; .- --
•
County .' • lr4W.)f' IAfd •jio' Cotoci
... .. PaioelIdenti5oahanIdo »� • ZN •�D .
. :'. ' Sb.Latitudeand longitude Indegrees/niinuteslaecondaordeciinalidegrees.: 1 . • - . .
....... �(ifwell field,�:om lat/lotig is saffictentj • . . - .. . '.: - .. • � .
• - : .22.Certitieation. 1• '
3 gip' .���'' N . 78° ,='ss.0�'0 ... '• •• ✓•.0/ram-
• 6.ia(Rre)the weU(s) ermanent or Tem
. Date
of C sad w contractor
-•., • • - -• • - .: : • • signing this forts,1 hereby aeli6 that the well(s)was liver)cotis!mded 1n•aecorrlmrce:-: 7.Is this a•re rig . .
1�tb-an.eals6 well.. � oa QNo� - .. - �r ISANCAC 02C 0100 or.lS�INCAC 02C 0?OD Wd!Corwiuctlon Syanda�s•ond that a 'trims is a repair,fill out loiown well canstrualpn:lajb inatloa and explain lhennfure gfthe: copy.old ill reepid,hasGeen provided to the well ark?...
' reOlt index 021►emarkssectlon or pi the back°Phisfonn.'. • : .
-• • • • .• :. 23. Site diagram or additional well details.•: - •
.- 8.For Geoprobe/DFT•or Closed-Loop Geothermal Wells having the same... " You•i ay use the back of this pa o 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 aciditiOpat pages.if necessary..'
• ' • SUBMITTAL INSTRUCTIONS '
. . 9.Total well depth-below land surface : 44 Cf ':• . (it.) •24a.For Ail Wellsb. Submit tliis!fonn:within•'30
For multiple xrllaltst all depths Ifdiperent(example-3(a)Z00'and2®100') :.. .- ' -:. - completion Of.well •: ''
consWtnion to the,following: • •. das��:
10.Static Isis-elev.el below top of easing:• - -•. (it:) • Division of Water Resent lfwarerlevel Js above easing use +' ces,Information Processing Unit,
• /� • • •• 1617 Mail Service Center,Raleigh,NC 276991617
. I'.Borehole diameter: •• •• 6 -_ •(in.) • 24b. or foliation Wellit •In addthon to sending the form to•the address in 24a .
12.Well Construction method: - �/�• �'y .. - . above:also submit'one copy.of this form.within 30 days of completion•of we1f. .• • ,• •
(i.e..auger,rotary,cable;direct push,•etaJ - . : : construction to ttie following: .
•
. FOR WATER SUPPLY:WELLS ONLY;
• - • Division of Water Resources,Undergrotud infection Control.Program,• .
. • : • ter,Ralelgd NC 27699-1636 . . . '
•
(gpm) of. : Method of test:: :
13a.Yield � . .• . . � • ..
636 Mail Service
24t.For Water-SaaDly&IDi on walla:.ht addition to_seiid'mg tfie form to'
13b:Disinfection - - • ' the (es above, also submit'one Copy of this form within 30 days of .
typ r • , •• Amount: .. • completion of*ell construction to:the;county.health department of the county .
wberc constructed
Form GW-1 North Carolina ,I>e[iattnient ofSriviromnental Quality Division of WaterResourirs
'Revised22anr6