GW1--03657_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
M( 'l r K ,Ai I n 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft, ft.
3 Z it; A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applkable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft. "I`i. ft. u)1c� im. pve/
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
' t �� ,(IL/j 1 v���� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft: w ft. 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 MATERIAL
ft. ft. In.
❑Agricultural ❑Municipal/Public
DGeothermal(Heating/Cooling Supply) ,esidential Water Supply(single) to ft. in.—
❑industrial/Commercial ❑Residential Water Supply(shared) 18•GROUi-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Obligation 1 ft A It.
/)t ,r 1-�ic �^ J
\a�f
Non-Water Supply Well: ft. ft. l' 1 , l
O Monitoring O Recovery
Injection Well: ft. It
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier n. ft.
❑Aquifer Test ❑StormwaterDrainage ft ft. —
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,saiIrock tspe,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I it. Ct 1 l f. v) h- ,k .ir t/-Il-
4.Date Well(s)Completed: 2A-- Well 1Dk "L ft, Cat R ^�l l�lk l ' t� 1
ft. l)lJ� ft. r l t
5a_Well Location:
1 it. ft.
J ohrir11' oh er{-Son ft. ft ( C�\r) -O
Facility/Owner Nam Facility ID#(if applicable) it ft. JGt 1
'SDl N tar 4-h Ho u 1�d .• oCK L ft. ft .YAT‘r-p-V- I.1�.
11v�
Physical Address,City,and Zip {� .k C 21.REMARKS `a A i`-Li
MED0 t',)(),\. .1 UN 1 8 2D24
County Parcel Identification No.(PIN) r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 221 Ce 'frcatio : _ r,f41ts4.-,c r
(if well field,one 1st/long is,sufficient) r� �j CM:411•C 4
i ._::-Vz-N----- ,... -2(-'
Sigma ofCertified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary_ By siva, this fain,I hereby certify that'he.ell(s)was(item)co,otruried in accordance
with 15AJ CAC 02C A100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: (Wes or i io copy of this recur,!has been provided to the well miner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under tt21 remarks section or on the hack of this form. 23.Site diagram or additional well 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 supply wells ONLY with the same construction,you can
submit one fin in. tt SUBMITTAL 1NSTUCTiONS
9.Total well depth below land surface: 8 V J (ft.) 24a. For All Wells: Submit this fcrm. within 30 days of completion of well
For multiple wells list all depths ifdilferent(exempt'-3(d200'and 2@a I U0') Construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center.,Raleigh,NC 27699-1617
dI l
I 11.Borehole diameter: Li) U (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
� �` above, also submit a copy of this form within 30 days of completion of well
��
12.Well construction method: L' 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 2 769 9-1 636
24e.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) J Method of test: l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environnxnt and Natural Resources-Division of Water Qual Icy Revised Jan.2013

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