GW1--04070_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
M rk Y K ..1 I �1 1 14.WATER ZONES
113113=111110 DESCRIPTION
Well Contractor Name ft. ft.
,3 Z:S i A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased welisCOR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. t/i- in.
V
Company Name 16.INNER CASING OR TURING :eothermal closed-loop)
� }O( /', / ( _ 7 3 FROM TO DIAMETER —THICKNESS MATERIAL -
2.Well Construction Permit#: if Ol t�lj ft. ft. DIAMETER
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: Ira21111.11102111111111.11CIRIZIEN SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural °MunicipaUPublic
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) _
°Industrial/Commercial °Residential Water Supply(shared) 1&GROUT _
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation .) ft. /-/ /i /9/21.0. c�
Non-Water Supply Well: l
ft. ft.
❑Monitoring ❑Recovery --
injection Well: ft. ft.
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a i.livable)_
FROM TO MATERIAL EMPLACENIENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑StormwaterDrainage R. ft.
°Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) °Tracer FROM I DESCRIPTION(color,hardness.soilirvek Noe,grain size.etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) l H' W-4 a�,(
- ay3Ve11 1D# a ft. -slIL G�r�.�.t1�ie
4.Date Well(s)Completed: {�J (L f ft U�i ft. L / i% it
Sa.Well Location: ) '� ft. I�S f. / M�C/iw
..0 k - e
'
Facility/Owner Name FacilityiD#(ifannlcablel ft. ft.
`)961 Al I tai-yjLf1'A1 _r, lbuon_1'11_ H. I. t i1 1 d 2024
Phy3al Address,City and Zip NL 21.REMARKS A y 3'r^ ",‘UFA
AtC-ttll e Y T o yV MCI SC.;
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C -
(if well field,one tat/long is sufficient)
:35' Lig EF 937 N S1 0 5 9 W 3 3 / W ad C����� -/ 6) & _02
Signature f Certified Well Contractor i Date
6.Is(are)the well(s): [ eranent or ❑Temporary 0),sign'? this farm hereby cerr u ns•that the ell(s)tins(mere)constructed in accordance
/ \ tn with 15A tiCAC 02C.0100 or 15A,VCAC t)2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or , iNlo copy of this record has been provided to the well owner.
I f this is a repair,fill out known well conavraction information and plain the nature of the
repair under N21 remarks section or an the back of this farm. 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 suppl t•ttvlls ONLY with the same construction,you can
SURNI1 CI'AI_1NSTUCTIONS
Inflow anoint m.
9.Total well depth below land surface: 705 1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i different(example-i d,100'and 40 0(P) construction to the following:
((l1) Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: (ft') 1617 Mail Service Center,Raleigh,NC 27699-1617
If:sorer level is above casing.use'•+'• l
11.Borehole diameter: On.) 24b.For injection Wells: In addition to sending the form to the address in 24a
r) /ilk above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: i L/ ni construction to the following:
(i.e.Queer.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 63 6
r 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: , — the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Fors GW-1 North Carolina Department of Environment and Natural Resources-Division of water Quality Revised Jan.2013

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