GW1--05931_Well Construction - GW1_20230918

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: — Print Form
I.Well Contractor Information:
Reuben W. Clayton, III 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
2241-A jS,ft. i'S‘ fL /,o G Au&' z,zt-i/Le-
NC Well Contractor Certification Number ft. ft.
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIA5IETEI2 THICKNESS MATERIAL
Company Name �� ft. 7 2_ft. /L�v is sn2Z! I Fe/4
2 q 16.INNER CASING OR TUBBEYG(geothermal closed-loop)2.Well Construction Permit#: 3 ,G FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,euc) ft. ft. in.
3.Well Use(check well use): ft ft. in
Water Supply Well: 17.SCREEN
Agricultural �M FROM TO DIAMETER SLOT SIZE THICKNESS j MATERIAL
nicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) —
ft• ft. in.
Industrial/Commercial
DResideniial Water Supply(shared) —
Irrigation IS.GROUT
FROM TO MATERIAL- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. g,
Monitoring Recovery cxitAr !S'e�� 70;fief,
Injection Well: ft. ft.
Aquifer Recharge EGroundwaterRemediation ft. ft.
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(if applicabls,
EjSalinity Barrier FROM TO MATERIAL
Aquifer Test EMPLACE ENT ntr,HOD
Stormwater Drainage ft. g,
Experimental Technology DSubsidence Control ft. fr.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additionalsheets if necessary)
Geothermal(Heating/Cooling
Return) Other(explain under#21 Remarks) FROM 1O DESCRIPTION(color,hardness soil/rock type grain sae etc.)
4.Date Well(s)Completed: /'j,/23 Well ID# O fL fr "L( ,�L/�"
51
Sa.Well Location: 5-3 {t, 46 ft. 7i1�z4o.cio �O<G<
44.v0a4sW O'7-!•4.6 �� ft. t/ff ft. ��e!!G, /f-vc2ds
Facility/Owner Name Facility 1DII(if applicable) ft. ft.
4Z�`� 125E ex GvES 7Ci6�p 205) ft. ft.
Physical Address,City, 1y j'. !r�
and Zip ft. ft. � Li
I.7'0lrEr 21.REMARKS _ E n 1
County Parcel Identification No.(PIN) r 2023
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: UN
(dwell field,one lat/long is sufficient)
22.Certification:
3G/Q 2.2 `D 7�$` 3 N f ae/g r3 7/J7ew W 34/2-:;>6.Is(are)the well(s) ermanent or QTemporary. Signal theofCertified Well Contractor
D
By signing this facto,I hereby certi that the well's)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or g.No with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out knows well construction isfonnaiion and explain the nature of the copy of this record has been provided to the well owner.
repair raider 021 remarks section or on the hack of this forms.
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:
For multiple wells list all depths if different(example-3@200'and 2 t@100') (ft) 24a. For All S Submit this form within 30 days of completion of well
l construction to the f foollowing;
10.Static water level below top of casing: l7 (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: e./:f• (in.)
/� 24b. For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method /� /2 /Zp%/f�4 above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) 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) 6 uo. Method of test: f S/4te-- 24c. For Water Supply&Injection Wells: In addition to sending the form to
a ` the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 7U •'/f7,/Amount:`ors completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016