GW1--05016_Well Construction - GW1_20230807

I
WELL CONSTRUCTION RECORD(GW-11 For I Print Forrn
I internal Use Only:
1.Well Contractory/Information: I i vV
Reuben W. Clayton, Ill 14.WATERZONES
WcllConghact/
2liq
o�rName FROM TO DESCRIPTION
224 1 6`4 , ft. 2;2..11 2.0 Kt9 i
NC Well Contractor Certification Number ft ft.
fy
®�l l I t Inc. 15.OUTER CASING(for multi-cased wells)OR-LINER(if Raffle)Raffle)ap e)
q
1 FROM TO �i DIAMETER THICKNESS / MAIL
Company Name V./ ft 1 t ft I C f im J.r&/2.26 19Y.G
O FROM
16.INNER CASING OR TUBING.(t(geothermal 2.Well Construction Permit#: DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Ceumy,State,Variance,etc) ft ft. in.
3.WellUse(check well use): ft ft is
Water Supply Well:• 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�M icipal/Public 0 ft, ft. in.
Geothermal(Heating/Cooling Supply) 2fesidential Water Supply(single)
ft ft in.
Industrial/Commercial
Residential Water Supply(shared) 1S.GROUT
Irrigation FROM TO MATERIAL
Non-Water Supply Well: EMPLACEMENT METHOD&AMOUNT
it ft*Monitoring '°Recovery ft �L1�� /°DLf/Z�a��/Y1,/1�
Injection Well: ft /9 4,9AS
Aquifer Recharge [Groundwater Remediation ft. if.
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
OSalinity Barrier FROM TO
Aquifer Test MATERIAL, EMPLACEMENT METHOD
�Stolmwater Drainage ft ft.
Experimental Technology DSubsidence Control , ft ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets ifnecessaty/
et
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DFSCRnntoN eotor ranee,aotv,ocr,t ,grain
D ft 6 ft 4 64i9 4.Date Well(s)Completed:?//V/,2 Well ID# 6 ft. 4..0 IA
5a.Well Location: J'o f' S c ft, 7' . /..c.i1_,e,a0 2 {
CAI h///fhEl c. ft L4C ft' 40196' l/L4..ellre
Facility/Owner Name paciliity ID#(if applicable) ft ft
7-,3V,1 57'ccl.AV ag."-W,A,,�, Z 70 VG ft. ft ( >�.. r -b td+� r
Physical Address,City,and Zip ft. ft. 7 1.
-
/ xe�s 21.REMARKS '0- L U2.j
t�
County Parcel Identification No.(PiN) < _rr '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,�` t"
�tf+Ltri.?v(if well field,one ladlong is sufficient)
22.Certification:
?''2S=0S.S✓s.2 N So° 0812/.9732 W t l_z_zet_i_<.?to
6.Is(are)thewell(s) Permanent or Temporary SignahaeofCertifiedWellContractoorr
�� By signing this form,I hereby certify that the well(s)lies(were)constructed in accordance
[Sjls°
7.Is this a repair to an existing well: ElYes or with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well construction informational',"explain the nature of the copy of this record has been provided to the well owner.repair wider:121 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
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
Z5 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fd�erent(example-3@200'and 2@l00')
construction to the following:
10.Static water level below top of casing: CU (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 diameters O/$ (in..))1 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /4, /Li/79/ul above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,eta 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
13a.Yield(gpm) 2..Q Method of test: %/i414.49 24c.For Water Suomi a:Injection Wells: in addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 76/b I/ ✓/Amount:: Le r 'Z 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