GW1--03201_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
t V l c r(( ki .e.t 14.WATER ZONES
!\ t tr)1 FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3 Z. A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cued wells)OR LINER(if applicable)
FROM I TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling inc. I n. i�5'u ft. LQ., „— �`,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 1
02 2 _ t V` 3 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: '-'---ifL ft. in.
List all applicable well construction permits(i.e.County,State,Variance,etc.) _
ft. ft. in.
3.Well Use(check well use):
17.SCREEN — -
Water Supply Well: FROM TO DIAMETER SLOT SIZE - THICKNESS MATERLAL
❑A ricuitural ft. ft. in.
g ❑ unicipal/Public
❑Geothermal(Heating/Cooling Supply) Kesidential Water Supply(single) n' n in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.
OM GROUT
FR TO MATERIAL EMPLACEMENT METHOD a,AMOUNT
❑Irrigation ii Tye 4
Non-Water Supply Well: ft
' 1` R. Ce t t enA- mi y.. f tl
❑M �Y
onitoring ❑Recov ft. ft.
Injection Well: ft. ft. —" -
QAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fir. ft.
Cl Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control _
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness.soil/rock t,pe,grain size,tie.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks). 1 fit• I O u ft- �'L A, (-IA'r
4.Date Well(s)Completed: Well iD# I S R. �� rill
a.Welt Location:
360 ft. .G t+ ft. 1 i 6
h \ r e . �u2 k. F.,ft- r in.'1-1 i
ft. ft. f
Facility/Owner Name Facility iD#(if applicable)
ft. ft
33 HA—. P Cif tura) ft. ft. ......,.,
Physical Address,City,and Zip `
0C 21.REMARKS MAY m .124
P-)\Lr\Cci^\he
County Parcel Identification No.(PIN) '�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C4elliflWellConor
fication:
kii.,_
(if well field,one lat/long is sufficient)
Signs Date
6.Is(are)the well(s): Permanent or ❑TemporaryBJ'althis form.I hereby certify that the nell(sl was(Here)constructed in accordance
with 15A NCAC 02C.0100 or/SA.VCAC O2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or t$ji(lo copy al-this record has been provided to the well miner.
/(this is a repair,fill out known wen construction i,formation and erplai r the nature of the
repair under#21 remarks section or on the hack of this form. 23.Site diagram or additional welt details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supple wells ONLY with the same construction,ytto can
submit one_Bunt SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 0 5 (fit,) 24a. For All Wells: Submit this form within 30 days of completion of well
Fin.multiple nr1Li list all depths ffdl/)ere,u(e ample-_WOO'and 2 dd00') construction to the following:
10.Static water level below top of casing: U 0 (ft.) Division of Water Quality,Information Processing Unit,
if.:wet.level is„pace casing,use"+' ` 1617 Mail Service Center,Raleigh,NC 2 7699-1 6 17
I I.Borehole diameter: (.) ;2 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�
�V 1 ^ � above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: V kai ' construction to the following:
(i.e.auger.rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U) Method of test: 2 iCi 24c.For Water Supply&injection Wells: addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form ow-i North Caroline Department of Environment and Natural Resources--Division of Water Quality Revised Jan.2013