GW1--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