GW1-2022-10832_Well Construction - GW1_20221209

i
Pfinit Form
WELL(CQNSTRU CTION RECORD(GW-Ill For Internal Use Only:
1.Well Contractor Information:
Reuben W. Clayton, III 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTTON
/•�G ft. ft
2241m�
NC Well Contractor Certification Number ft ` � ft.
15.OUTER CASING for multi-cased wells OR LINER tf a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MA/T�ERIAL
Company Name / ft 117 fG K, in. � �,L' !✓
q 16,INNER CASING OR TUBING eothermsl closed-limul
2.Well Construction Permit#: �!/ � FROM I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction pennits(i.e.UIG County,State,Variance,eta) ft, ft in.
3.Well Use(checkwell use): & ft in.
Water Supply Well: 17.SCREEN
ITLOM TO DIAMETER.' SLOTIZ SE TRICKINESS MATERIAL
Agricultural tricipaUPublic 0 ft ft. in.
Geothermal(Heating/Cooling Supply) BRe idential Water Supply(single)
' industrial/Commercial OResidential Water Supply(shared) 13.GROUT
' Irrigation FROM TO MATERIAL EhiPLACEMENT.METHoD.&AMOUNT.
Non-Water Supply Wem Q It
Monitoring r..Recovery ft. ft
Injection Well: lL r
ft. tL
Aquifer Recharge oGmundwater Remediation
19.SAND/GRAVEL PACK fifanplicithlel
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMEXTMETHoo
` Aquifer Test DStomtwaterDrainage ft. &
ExperimentaiTechnology OSubsidence Control ft &
Geothermal(Closed LOOP) [3TIaeet 20.DRILLiNGLOG attach additional sheets if access
Geothermal(Heating/Cooling Return) ClOther(explain under 921 Remarks) FROM I TO DESCRHaTON rotor,haraates soiUeoc[c a ins ze etc
—jr ft.
4.Date Weil(s)Completed:lj '/ ,'r''We1I mm �! ft 5� ft.
So.Well Location: AV
fr. ft.
/" ft ft
Facility/Owner Name Facility IDS(if applicable) f l L ft < ft
63r�Z�� �i �/L /lU�'s��✓;S Lc"�r ft ft
Physical Address,City,and Zip 2—..."2_7 ft ft
--/7! 21.REMARKS _
County Parcel Identification No.(PIN)
�'&. ftfl%1'P116S ui r"f..:.!/tu Grc�tj
5b.Lntituiie and longitude in degrees/minutes/seconds or decimal degrees: ryM1 /A _
(ifwell field,orie lot/long is sufficient) 22.Certification:
6.Is(are)the well(s)_. ermanent or Temporary signaturoofCertifiedWellContractor (, D -e
By signing this form,I hereby certify thct the wells)bras(were)constructed in accordance
7.Is this a repair to an existing well: nYes or rINo ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knm m well construction information and explain the mature ofthe ropy ofthis record has been provided to the well owner.
repair tinder 421 remarks section or on,the back ofthisfornt. 1'
23.Site diagram or additional weli'details:
S.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: SUBMITTAL INSTRUCTIONS I.
9.Total well depth below land surface: (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifAfjerent(example-3@200'and 2�1a 100) construction to the following.
10.Static water level below top of easing: SG' (ft) Division of Water Resources,Information Processing Unit,
lfrrmter level is above casing,use^+^ 41 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In additionito sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of thin form within 30 days of completion of well
�//L �� !�
(Le.auger,rotary,cable,direct push,etc.) construction to the following
]Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,]Raleigh,NC 27699-1636
13a.Yield(gpm) Z 5� Method of test 77,7,- 24c.For Water Sunnly&Iniectioi Wells: In addition to sending the form to
the address(es) above, also submit Rorie copy of this form within 30 days of
13b.Disinfection type: ,21�6mmount: completion of well construction to the]county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmentat Quality-Division of WamrResomces Revised 2-22-2016