GW1-2022-01668_Well Construction - GW1_20220128

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Reuben W. Clayton, 111 14.WATER ZONES .
Well Contractor Name FROM TO DESCRiMON
2241 A ft. �; ft.
fL ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa licable
� FROM T�O DIAMETER THCKNESS AIATERALuD^�(�rIn�.` ft. in.
Company Name f /yo
�.� 16.INNER CASING OR TUBING thermal closed-l000l
2.Well Construction Permit#: V FROM I TO DiAMEM TfficRym MATERrAL
List all applicable ivell cansiniclinn permits(.e UIC.County,State,Variance,etc.) fL fL in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
DIAA417'ER SLOTSt7M THICKNESS AIATEML
Agricultural �MunicipaVPublic 0 fL FROM TO fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. I is
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENTAfETROD&AMOUNT
Non-Water Supply Well: 0 ft. 1 fL ) 0gAA d' y,PA4 ,�fd
Monitoring [Recovery ft. ft. 6 ��
Injection Well: ft.
Aquifer Recharge DGroundwaterRemediation
19:SAND/GRAVEL PACK(if a licable
Aquifer Storage and Recovery oSalinity Bartier FROM TO I MATEWAL EMPLACEMENTMEMOD
` Aquifer Test nStormwater Drainage %
Experimental Technology rjSubsidence Control fL fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FlOther(explain under 921 Remarks) FROM TO DESC JMON Color;bananas,soatroek type,grain sae,ete
O fL 7 ft.
4.Date Well(s)Completed: "30Well ID# 7
ft' /21 ft'
5a.Well Location: I Z4 ft /L ft fn%Ovw O(/Z
2,9 ft' 2-CS ft.
Facility/Oivner Name Facility]DO(if applicable) ft. ft. `
fL fL JAN
Physical Address,City,and Zip ft- fL
n n 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ivell field,one latilong is sufficient) 22.Certification:
`el7• 6 /N �r�'`Q l/Es.
- ,� ! zL
6.Is(are)the well(s)-� Permanent or Temporary Signature of Certified Well Con or ! ate
By signing this form,I hereby certify dial the well(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: rilYes or 2 rNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cmistrrrction Standards mid that a
Ifthis is a repair,fill out known ivell construction information and explain the nature ofthe copy ofthis record has been provided in the ivell owner.
repair under;:21 rentarlis section or on the back ofthivform.
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 1 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: (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
Formn riple wells list all depths ifdifferenr(example-3@a 200'and 2@100) construction to the following:
10.Static water level below top of casing: `7 7 (ft.) Division of Water Resources,Information Processing Unit,
If surer level is above suing,rise"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. !�a_(in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this fonn within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to die following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
Q 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) y Method of test: ReV 24c.For Water Supply&Iniectio�!�4r n Wells: In addition to sending the form to
740�� /�� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: !X'0Z completion of well construction td the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016