GW1--03662_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
1rt.r K A-I 1.e.t 14.WATER ZONES
n' FROM TO DESCRIPTION
Well Contractor Name ft. ft.
, 2-?I A ft. ft. -
NC Well Contractor Certification Number 15,OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER. THICKNESS MATERIAL
Clearwater Well Drilling Inc. r rL /r D ft' �� in. fi ",1, -
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 5/A)V"- I °CI 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
❑Agricultural OMunicipal/Public ft. ft. in.
['Geothermal(Heating/Cooling Supply) tilResidential Water Supply(single) ft. it. in.
❑industrial/Commercial 0 Residential Water Supply(shared) It.GROUT
FROM 1'O MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. 2O it Drell rit
Non-Water Supply Well: (Drell G• ix.,
❑Monitorinb ft. ft.
ORecovery _
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Storage and Recovery OSalinity Barrier ft. ft.
0 Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
2o.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,kardnes.suiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ! ^rt. `Q,r(�'� it. C�j R-�T! 14o.
- ,•Y{
- rJ-2`t' 11VR' OtV - at �J
4.Date Wel(s)Completed: Well[D# +� ^
5a.Well Location: +. -y' 1 t 1 OSt k- tO R' l ► s '
C�S.)11 1CS $1 n ►OdSft >
Facility/Owner Name Facility iD#(if applicable) fL ft t'- {. f Z
303 Wolf�etn \ F. aOc ft
t 5 )C, . it.
Physical Address,City,and Zip 21.REMARKS ,U N 1 8 2024
Memo e._t.k _ ion:, �.'-
County Parcel Identification No.(PIN) �a 4
it CYh' ,11i t j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.t ertifcation:
(if well field,one lat./long is sufficient) i
35' 54�5 0 31 Tr N 32 1 Li D 3R 39 W /1.•Vi K 5�1�1 -Z`1�
Sig ndture of Certified Well Contractor Date
6.Is(are)the weli(s): Permanent or OTemporary By signing this farm.1 hereby certij'that the nelt(s)ties(mere)constructed in accordance
with 15A NC.4C 02C.0100 or 15A,YCAC'12C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or Vlo copy of this rlscard has been provided to the well owner,
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 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
B.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
erdvnir our fist,n SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: J ' (ft.) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple sells list all depths if di1/erent(example-ir(,•2011"and 2 c@1110') construction to the following:
10.Static water level below top of casing: Q0C (ft.) Division of Water Quality,Information Processing Unit,
if eater lacel is above rasing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
(i L Borehole diameter: 1 3 (in.) 24b. For Infection 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: 1 (J f 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; t636 Mail Service Center,Raleigh,NC 27699-1636
9 x- 2.C 24c.For Water Supply&injection Wells: In addition to sending the form to
13a.Yield(gpnm) Method of test: I 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.
Fonts OW-i North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

WA Wear SaiMitrout Codification
owner
New Welt_
Adars-� w
PP.xln1tz SLA]ada ` 4
I hereby certify that the above referenced well was grouted
in appearance in accordance with
all County Well rules.
tea- r IL ku� signed: A/tAld
wen per:
certfficate : 3Z Q -A- _ Dote,Grouted:__ ___
Construction:
Total ,: 100 S Tx
Caftg TYPe: c mt1�.L
Casing : 1lQ z�
Diameter: ti2 �$
w /T ,
Height
Drive sloe:
GPM: ":.