GW1--04105_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD for internal Use ONLY:
This faun can be used for single or multiple wells
I.Weil Contractor Information:
Mi r K A- ^iFRo iA7 TO _ DESCRIPTION
Well Contractor Name R. ft.
is.OUTER'CASINO
NC Well Contractor Certification Number t (tar mold-caged wells)OE LINER(If apes bR)
MOM TO , DIAMETER THICKNESS [MATERIAL
Clearwater Well Drilling Inc. / & 69 i . n• (.i�%E t"• 11 /)�,vL%
H16.INNER CASING OR TUBING(geothermal closed-loop)
Company Name ff `�hpM TO DiAME 8R THICKNESS MATERIAL
2.well Contariteuon Permit N: C - <2002 4- " 0 310 R. R. In.
List all applicable well construction permits(l.e.Comity.Stoma Variance.etc.) 1--- —
ft. ft. In.
3.Well Use(check well use): ^17.SCREEN
MI
Water Supply WeWell: �VROM TO DIAMETER SLOTZS THICKNESS MATERIAL
R. R. /n
❑Agricultural ©Municipal/Public
DOeothetma►(Heating/Cooling Supply) esidential Water Supply(single) n" R. in.
(H g g npP Y) � g )
Olndustrial/ t8.GROUTFT<QM Commerciat ❑Residential Water Supply(shared)
TO MATERIAL 6M11<ACiFN�fT METHOD�AM°VNT
nigation —/ R. :9�% R. (2f'r/ ?t in/(l../a'
Non-Water Supply Well:
ft. ft.
❑Monitoring CORecovery
Injection Well: R. R.
OAquifer Recharge ❑Groundwater RemediationTiR SAND/GRAM PACK(if hpplkablc'L
FROM hOM
❑Aquifer Storage and Recovery OSalinity Barrie- R TO " MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage — of ' rt. -- —
❑Experimental Technology OSubsidence Control
?E.DRILLING LOG(Muth additional sheets If necessary)
DOeothemaal(Closed Loop) OTracer FROM , TO DESCRIPTION(alor.►e$ges aailtraelt Imopiralaallesn-)
OGeothermal(Heating/Cooling Return) ❑ 1 I
Other(explain under 421 Remarks) / n• ' V R. c Syr {t--d if f'
4.Date Well(s)Completed;V 1`3 oc Well MNft, 5 70 n. ra J -
570 n. 5.7/ ft, e,t!"- �1'c
Sa.Well Location: ` // ��1/R. ��- n. qzziik
15/7 >?C1.YC(�/ eQ1X t�C/ /tc, isR. n. '
Facility/Owner Name (1i1" 14 5- /✓ ' Facility lDk(if applicable) ft. ft. �'r_.! /E L.,
Spin 2 12/t71225 t euue —' ft. ft. 1 2 Z0�4
Pteh ►Ad*- Y.red71p 21.REMARKS
/- /?d e/";SO/7 -ales.'-f I I
County Parcel identification No.(PiN) / "�'y
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Clt does
(if well field,one IaUlong is sufficient)
c7, /U N Lit &'&.. d)c w ' 4-- t �`7 �y
: . 3/
Sinai ro f fCertified Well Contractor Date
6.is(are)the well(s)�1�3`Permanent or °Temporary By signing this form.I hereby certjlj,that the ttel!(s)nos(mere)constructed err accordance
with 15A NCAC 02C.0100 or 15A NCAC OMC.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or o copy of this record bar been provided to the well owner.
if this is a repair,Jell out knoaw well construction information and a lain the nature of the
repair under#11 remarks section or on the bock of this form. 23,Site diagram or additional well details:
You may use the back of this page to provide additional well silt details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-wester supply wells ONLY with the some construction,yrm can
subunit one firm. SUBMITTAL INSCUCTiONS
9.Total well depth below land surface: �C s (ft.) 24a. For AU Wellg: Submit this fhim within 30 days of completion of well
Far muilpfe wr/ls list all depths if different(example-.1/)200'aml2(a@1OM) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
if tinter level is oleic casing,use"+" ( 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: c / S' (in.) 241r.For Injection Wglls: 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; f 7 o -(V f/ c.w.o..the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 636
13a.Yield(gpm) Method of test: /2/ C, 24c.for Water Supaiv&inicclion Welts; Ip addition to sending the form to
the address(es) above, also submit one copy of this fort within 30 days of
tab.Disinfection type Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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