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HomeMy WebLinkAboutGW1--03655_Well Construction - GW1_20240618 (2) WELL CONSTRUCTION RECORD For Internal Use ONLY: This form can be used for single or multiple wells j 1.Well Contractor information: I /(a r t/f� AlI y n 14.WATER ZONES lv 1 l I FROM TO DESCRIPTION Well Contractor Name ft. ft. 3 2 G .A ft• ft. NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) FROM TO DIAMETER THICKNESS 1 MATERIAL Clearwater Well Drilling Inc. / ft. ��� a. �n if i55,, fG� Company Nam. 16.INNER CAS[NG OR TUBING(geothermal dosed-loop) j4I3 FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#: tt- ft. to. List all applicable Well construction permits(i.e.Caate, Variance.etc..) ft. ft. in. 3.Well Use(check well use): 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑ ricultural ft. ft. in. ❑Municipal/Public ❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft R. in. ❑lndustrial!Commercial '❑Residential Water Supply(shared) IS.GROUT ❑Irri [IOR FROM TO MATERIAL. EMPLACEMENT METH D&AMOUNT Non Water Supply Well: n. f�I ft. j /)/YJ�y �L i/, �� ft. 1 ft. Cl�lI ❑Monitoring ❑Recovery Injection Well: ft. ft. — ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicab) FROM TO IHATERIAL EMPLACEMENT METHOD _ ❑Aquifer Storage and Recovery ❑Salinity Battier n H _ ❑Aquifer Test ❑Stormwater Drainage ._ — ft. ft. ❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets If necessary) OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION`color hard ,saiUrock mac,grain size,etc.) OGeothermal(Heating/Cooling Return)l ❑Other(explain under 112I Remarks) //,tL ft- L41 . it' :Egli 1�,-/� ��, - 4.Date Well(s)Completed �2 Jt Well ID# (,f T R S 7�If J t�(;!//J / "7, � 762ft. ± 77 ft' (/� ' v 5a Well lion; 1 ' ft n : `.•L.' Facility/Owner Name Facility IINI(if applicable) R. ft 4/576- � , y �Y I) /1( i/S ft. il.h 1 8 2021 Physttal Address,Cityond Zip t 21.REMARKS , i I URI `- 'T"-� r(.( ti County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certi ca n:(if well field,one tat/long is sufficient) • Welu l `-/ N l /7��/[ L e W � / ,/, � c !J/ Si o Certified Well Co .r, .r Date 6.Is(are)the wetl(s): Permanent or DTemporary By signin this fan,.1 hereby certify that the well(s)sus(Mere)constructed in accordance with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: DYes or YNo copy of this record has been provided to)hr tsell osner. If this is a repair,fill out knosn sell construction information and explain the nature of the repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details; You may use the back of this page ty 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 supply sells ONLY with the same construction,you can submit one funs, / n/n SUBMITTAL INSTUCTIONS (.9.Total well depth below land surface: .p(.l�C (ft.) 24a. For All Wells: Submit this loon within 30 days of completion of well For uudtiple sells list all depths ifdi/(cent(example-3(a.2000/'oond 2@/00') construction to the following: ! l,/ 10.Static water level below top of casing: 0 (ft.) Division of Water Quality,Information Processing Unit, If safer level is ol:ose cursing.use-±-i 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: L p I, (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a /q above, also submit a copy of this form within 30 days of completion of well 12.Well construction method: �� (.(/�y(� construction to the following: (i.e.surer.rotary.cshlc,direct push,etc.) Division of Water Quality,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 C! 24c.For Water Supply&Injection Wells: In addition to sending Yield(gpm) 1} Method of test: the form to the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: Amount: completion of well construction to :he county health department of the county where constructed. Form GSA-I North Carolina Department of Environment and Natural Resources--Division of Water Quality Revised Ian.2013 f map Axis awu ,'t, o) :Jammu o e : A#2 ht4c1KI plzfuf : - ,i :adtC1 - -{;Aga -- o ecGrilipc -� 19/7/= aiWcxxwm. inn 2p ametuane ui,anue.noci.cle u!peanau8 a ,v Ram peck a A t 2 1 — -- , 4061.11.5