GW1-2021-03231_Well Construction - GW1_20210624

For Internal Use Only:
I.Wall Contractor information: `
Reuben W. Clayton, 111 14.WATER ZONES
Well Cotasatxor Name TLt aBs ON
2241-A 2021
q
NC Weil CotittactorCertilt"an Naaiber J U N ,q G 4 L4 L1 R" ft.
IS Ot3RER CASING for multl�ed wells OR LMR a ble
Aqua grill, Inc. n Pr cessing our TO Dot im Kmos M4TWAL
Company Nntae DVV e , / ft. iL ia. f
�+ IG.INNER WING OR TWIM tbaraud ao
2.Well Construction Permit ft. 3 �M TO DUMB F
I.ist all applicable well aurslrotalmtpermits(i.o r11C.C—W.Stare.vasrmrm etej % IL
3.Wall Use(check welt use): %
Water Supply Well: rT SCREEN
FROM I TO I DIAM= I SLOTSM I TBWMMU I hy►TEtUpL
Agriauitttral
"imp
impattPublic 0 ft. tt- ia.
Geathetmai(HeatinglCooling Supply) esidentiai Water Supply(single) !l. R in.
IndustriallCommercial nResidendai Water Supply(shared) 1a.GROtrc
4
hri on MOM& EM1rPLACEarSNTalBfROD "tam I
Non-Water Supply Well. C, !/�.S 1,410416A v( d'
Monitoring Recovery % tt
injection welh R.
Aquifer Recharge g.2CirOw►thvatel Reraediation 19 SANOIGRAVEL PACK ire icable
Aquifer Storage end Recovery Osalil ty Barrier FROM To a7ATEnIAL EMPLACEIYlENTMhlROD
Aquifer Test [3Stornitvater Drainage f. IL
Experimental Technoluff 13Subsidence Control tt %
Geothermal(Closed Loop) OTMOV VDIULUIGLOG attach ad anatsheets.N
Geothermal{Heatin Coolie 44m ry Mt
Cher( lain under 01 Remarks � D iv cetortuuda saehocTi a u�d4 a ! � &�l.Date WcH(s)Completed: �P/ellID# fL -So.Well Location. Z, "L
Facilityl0ivaerName - FaciiityJDO(if applicable) 71 % ZW-L- ivy
Physical�A^d&=.City.and Zip 7,7 4 02- & R'
21.REMARKS
County F*W IdentilicatiouNo.(PDQ
Sb.Latitude and longitude to degrees/minutestseconds or decimal degrees:
(if wall fleid,one latflong is saf icumt) 22.Certification:
6.U(are)the well(sof rlrlanent or 131remporory Sigmatum of Cauca)Well Contractor Ddre
By slgnhtg this ferns.I hereby ceno dial the uell(s)was(were)catutriaxed bt accasrlmmv
7.Is this a repair to an existing well: 13Yes or D with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVeii ComMidlaet Standards and that a
Ifthis is a repair ffllONAnaun iveflcawructimi ti{(anmian and explain the nature afthe copyofthia rocardhasheeti provldedio the isatll aivner.
--=ojW-riot*rTMllrema,Arseetianoranthebackgjwlsfam 23 Site diagram or additional well details:
8.For Ceopr obelDPT or Closed-Loop Geothermal Wells having the same You may use the back of fhis page to provide additional well site details or well
construction,only I OW-1 is needed. Indira c TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled,• SUtiik ITTAL iNSTancirio
9.Total well depth below loud surface:, , �fl..) 24a. For Alt Webs: Submit this fort within 30 days of completion of well
rartmddple wellsfia all depthalfdWatrmt(example-3(dt200'mid2@10*
j construction to the following;
10.Statie water level below top of tasslog: ! (iL) Division of Water Resourcis,Information Processing Unit,
lf3raw10ttd isabaw aashtg,ass"+" 1617 Iblail Service Center,'Raleigh,NC 27699-1617
11.Borehole diameter. t�I ` Qu.) 24b.For Iniection Weiist In addition to sending the form to the address in 24a
!� d T� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to.the following:
(i e.augc,mtsty.cable.dinP,ot p-k ore.)
Division of Water ResomU4 Undergirouud Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Hall Service Centel,Raleigh,NC 27699-1636
139.Yield(glint). C/1 lVethod of test•['}„ fTr � 24c.For Wnkr Supply do law- floe We11st hi addition to sending the form to
the adthecs(es) above, also submit one copy of this fDrm within 30 days of
13b,Disinfection type:A/Z* M&_ Amount: ,ltS �' completion of vell construction to the county health department of the comity