GW1--07795_Well Construction - GW1_20231201

•
• Print Form. .•
WELL CONSTRUCTION RECORD(GW-yl ' :For Internal Use Only:
1:Well Contractor Information: • • ! •
•
".-Reuben W.:Clay on, I�� 14 WATER2ANE8 I
"
NC Will COnlisatorCcrtificatton Nundier • '
1.. Inc ' . -is OUTER CASINO(for mull-cased wells)ORLiNER'(ifip able) •
:A qua:Dri I I r n .•• : • • , . • ' • •• FROM '. - .TeOr • ' DIAMEETER _THICKNESS: .-: MATERIAL .._ • .
CoinpanyNama. • ,/ "• ft. 1 g e r (04.2. .
�f 2 /'') 16.INNER CASING OR TUBING(geothermal crosier-loop) - '
2:W 11 Construction hermit#:• .r.. ✓ w v •:•"• . _ FROM • ' TO ' • DIAMETER THICKNESS- _MATERIAL
List ail applicable well.aonstruction permits(i:e UIC„County,State,-•Variance eta) ft• ;+t•.• •j
• 3:Well Use(cheek well use) ' .. .. I,. :tn. : . . .. • -•
• ft. -:R'
Water Sopply'Well: , .. 17.SCREEN :. '
FROM: .TO: DIAMETER ';SLOT SIZE TRIMNESS MATERIAL
Agricultural: - DM `cipalfeublic' : .it .. tt . • :. iu.. . - • •
' Gegthennal eatin •'oolin .S l esidential Water Su l sin a -. .. . '
II _ 0 .
.. . � SIC 8 uPp Y) _ pP Y( � Bl ) {G _ (i:: io• ..
'. •' • Industrial(Commereial:' • DResideritial Water Supply(shared) . •
18.GROUT ' • .
Irrigation FROM`: TO MATERIAL- EMPLACEMENT-METHOD&AMOUNT'
. •• .'. Non-W Star Supply We1L • O' tt. it.
�tf :�rlS�.� �oatE�d/'ls�P.�
:. Monitoring • :• • . OReoovety _ :.. fr. fa'•Injection.Well:: ..: .1. . -
Aquifer Recharge DGroundwater Remediation - ••- • - :
- • • • • •" '19.SAND/GRAVEL PACK(if alispiable) . .
• . . Aquifer Storage 00lideovery. . OSaiinity-Barrier : '• • .FROM TO • • MATERIAL -EMPLACBa7F.Nr mention`
Aquifer Tait. • : . DStolmwaterDrainage • . •. : • -
Experimental Technology: ;.. .• • • :..Subsidence Control " • . • : . fe ft' .'
• Geothentlal(Closed,Loop). . • :• • ['liacer. . '20.-DRiLLiNG LOG.(attach additional sheets If ne ary)-
OM TO •' DES4CInPTtONnor n/mck .
. • • Ocothennal(Hating/CoolingReturn). •fOther(explain tinder#21 Remarks)- - ( ,Iin .eo paRn9nslraetal • ' .
4 �0
•
4.Date Wens)Completed f. AS *bit 11)#••' :
•Sa.•Well Location: . • .. . • • ft' 94' 6/1.,%Yi1._ .
�'® :fr.
•
FaoOi /Owner Name Facility IDS(if applicable)
`� " .:. . . - : � • " . q tII. YeS. tt �G��,F-�li�+t�;62�ui�?.ef
• physicalAddrtiss;Cay and2Sp. R R { �` �� ., r,
• 21.:REMARKS
Count ' . Parcel Identification No.(PIN)' D_ _ .
2.023
• Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
• (ifwellfield ones Iat/iongissuificiont) • i r.. ,.._-.._. lc t
�p- _ - , / . . . 22 Certification: • • • G:'`t � ;y •
•
'
S
6..IS(Ire)thewell(S) armament igianue'ofCettifed We11Contractor,or Temporary ' .:
- : ' •- : � • • By signing'this font,,I hereby cert//y 1Xat the rvell(e)rras:(ivere):constructed In accordance ' •
n ex 7.Is this a repair to aisting:welF Dyes .or rely° . . • • • rritlr15A NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standards andthat a• •
tfthis is a repab'fll out knottn well construction Information and explain:rim nature of the . ' copyof drir record lies beenpmvldedto the call owner. •
-
repair under 021;remarks section or'on the backofthisform. : ' ' • .
23.Site diagram or additional well details:.
B.Fort Geoprobe/DFF 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,oniy I GW 1 is needed.:indicate TOTAL NUMBER of wells construction details. You•may also attach additional pages if necessary. •
drilier� • - •--
` /r .� •
:SUBMITTAL 1NSTRUt:TIOT?8
9:Total weft depth belt)*land Surface .3 f3 nd :. • 'OE-) 24a: .For Ail Weil•si Subintt this fomi within 30 days of compleetion of well
For multiple hells list all depths ffdf fermi(ecemOle-3@200'and 2@100�' :. . '.Cons(manon to.therfollowieg .
•
•
• 10.S�tic water level below top of casing:.' . • So •' (ft) • Division of Water.R I urces,Information Processing Unit,
Ifwa►ei•level is above cosing.use"+". • . ' 1617 Main Service-Center,Raleigh;NC 27699-1617
: ., L eigb
11.Borehole diameter. / in:
•
' : ( ) - • 24b'for Infection Went; in addition to•sending die form to the address in 24a •
above,also submit one copy of this form within 30,days of completion of well
12.•Well construction method: •' ' s/in-G./0
g construction to the following
(t e,auge,rotary,cable,dicectpush,etc.) • • .
-• • -- • rces,C nd. and ejection Control Program,.
•Dtyisionof:WaterResou ergro Iq)
FOR WATER SUPPLY WELIS.ONLY: , • • • 1636 Mail Service C enter,Raleigh,NC 27699-1636 • •
. 13ii.Yield(gpm) .• - L .• • Met6od of to ii Z1./40; �. • •24c.For-Water Soplily&Inlectl Wells: .in addition to sending the form to
•- ' ' the addresses) above,:also stilitait:one copy of this form within 30 days;of
' • 13b.Disinfection type: �� �� Amount: Lv�O2- . -- completion or well construction to the county health department of the county
" where constructed. .
Form GW-I --Ninth Carolina Depaztment ofEnvimnmentai Quality-Division of Water•Reau i ea ' •Revised 2-22-2016
1