GW1--07125_Well Construction - GW1_20231101

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WELL CON ST l JCT1ION RECORD D((GW-Ill For Internal Use Only:
1.Well Contractor Informafiot:
euben W. Clayton, Ill
14.WATER ZONES I
We i Contractor Name FROM TO DESCRIP77ON
•
7 ./?0 ft.s 1
9l ft. f/zioAv
NC Well ContractorCenifiaation Number • GM ft. O3 ft. fi ®�'L
inc. 15.OUTER CASING(for multi cased wells)OR-LINER(ifs)) \(cable)
ua Drill, Inc. FROM TO . DIAMETER THICKNESS M/A�TERIAL
Co party Name ?1 ft 7 6 ft. l L, in. 504.2.1 I Ate/
. �.:r�`I 16.INNER CASING OR TUBBIING(eothermal dosed-loop) —
2. ell Construction Permit#: () `� / FROM TO DIAMETER THICKNESS MATERIAL
List II applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) ft ft. in.
3. ell Use(cheek well use): R ft i in,
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public 0 ft ft in.
Geothermal(HeatingJCooling Supply) residential Water Supply(single)
ft. ft. in.
Industrial/Commercial . DResidential Water Supply(shared)
Irrigation 1&GROUT •.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring Reeove 2,l' ����r49‘ "a2.zGd ff1"D Ap,
Inj lion Well: ry ft ft. ia �04s
A uifer Rechar ft. ft
Be i t Groundwater Remediation '
A uifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK(if applicable) - .
FROM TO MATERIAL, EMPLACEMENT METHOD
A uifer Test QStoranwater Drainage ft ft.
erimental Technology OSubsidence Control ft. ft
othetmal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary) - -• •
othennel(Heating/CoolingRetum) Other(explain under#21 Remarks) FROM TO DESCRIp17ON(cater.hardnes,.soilrocktype,amk dm.etc.)
Q` 0 ft. 9 ft. OC. y
4.D to Well(s)Completed: 7,/7/23 Well ID# 9 ft ft. .r
Sa. ell Location: L ft 44j fh . 'ySAIL-W S0110
L,Y•s T,MisEcigimr6 C3 ft 70 ft l 0 Z.
Facili y/Ouleters( ( iLao 5 Facility ID!,(ifapplicable) '7/ ft' .SIi ft' i9���� / e2g
Ale '-•1072 1Ale6CS //,emu-Le. .tJG "le ft ft. /J ` • !e
Pltysi al Address,City,and Zip ft. ft. f .'---s-�
.,._. •. y� I
� � n fl..i• .KJ per•, i
70, 21.REMARKS —
Coun, Parcel Identification No.(PIN) ryU V " T 20,3
Sb.L titude and longitude in degrees/minutes/seconds or decimal degrees: Ise, :;r:^'+•--, -,,.....__ .
(if we I field,one lat/long is sufficient)
Zs'/ q� 22.Certification: C>.•..Cy ;0 t ., ' "t
3� L7r S 9 N ? Zo'/ Y 9e(" W
P ry / ��L3
6.Is(:re)the wel(s) rmanent or Tem ors Signature ofCertified Well Contra
By signing this foam,I hereby ceri fy that.the well(s)was(were)constructed in accordance
7.Is t is a repair to an existing well: Dyes or �No with MA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
• if this s a repalr fill out known well constructionitformatton and explain the nature of the copy of this natant has been prorated to the wall owner.
repair alder 021 remarks section or on the back of this form.
23.Site diagram or additional Well details:
You may use the back of this page to provide additional well site details or well
8.Fo Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
cons ction,only 1 GW I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drills.: ;
�t�S SUBMITTAL INSTRUCTIONS
9.To I well depth below land surface: (ft) 24a.,For All Wells: Submit this form within 30 days of completion of well
Form Npie wells list all depths iifd8erent(example-3 a(�00'and2@a!00')
construction to the following:
10.S•,tic water level below top of casing: ‘09 (ft) Division of Water Resources,Information Processing Unit,
7jwate level is above casino uxe""+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.B rehole diameter: 44.,t; (in.) I
24b.For Intectipn Wells: In addition to sending the form to the address in 24a
12 W I construction method: fJ 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.YieldThr
(gpm) Method of test: /jJE 24c.For Water Supply&Iriieetion 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: 70%407#Amount: /Z 6 Z completion of well construction'to the county health department of the county
where constructed.
Fenn GW-I North Carolina Department of Environmental Oitality-ni„isi,,,.ofwam..D...,.,....... .. . --------